hospital_name last_updated_on version hospital_location hospital_address license_number | WA "To the best of its knowledge and belief, the hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date indicated." Adams County Hospital 2 5/12/2025 2.0.0 Adams County Hospital 2 903 S Adams St Ritzville WA 99169 HAC.FS.00000111 TRUE description code|1 code|1|type code|2 code|2|type code|3 code|3|type code|4 code|4|type setting drug_unit_of_measurement drug_type_of_measurement standard_charge|gross standard_charge|discounted_cash payer_name plan_name modifiers standard_charge|negotiated_dollar standard_charge|negotiated_percentage standard_charge|negotiated_algorithm estimated_amount standard_charge|min standard_charge|max standard_charge|methodology additional_generic_notes "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0001A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0001A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AETNA MCR ADV AETNA MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0001A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 12.73 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0001A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 COORDINATED CARE MCAID COORDINATED CARE MCAID 12.12 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0001A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0001A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MCAID MOLINA MCAID 12.73 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0001A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MCR ADV MOLINA MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0001A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0001A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0001A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0001A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0001A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0001A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0001A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0001A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0002A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0002A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AETNA MCR ADV AETNA MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0002A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 12.73 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0002A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 COORDINATED CARE MCAID COORDINATED CARE MCAID 12.12 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0002A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0002A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MCAID MOLINA MCAID 12.73 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0002A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MCR ADV MOLINA MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0002A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0002A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0002A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0002A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0002A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0002A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0002A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0002A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0003A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0003A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AETNA MCR ADV AETNA MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0003A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 12.73 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0003A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 COORDINATED CARE MCAID COORDINATED CARE MCAID 12.12 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0003A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0003A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MCAID MOLINA MCAID 12.73 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0003A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MCR ADV MOLINA MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0003A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0003A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0003A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0003A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0003A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0003A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0003A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0003A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0004A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0004A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AETNA MCR ADV AETNA MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0004A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 12.73 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0004A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 COORDINATED CARE MCAID COORDINATED CARE MCAID 12.12 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0004A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0004A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MCAID MOLINA MCAID 12.73 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0004A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MCR ADV MOLINA MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0004A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0004A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0004A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0004A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0004A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0004A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0004A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0004A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0011A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0011A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AETNA MCR ADV AETNA MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0011A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 12.73 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0011A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 COORDINATED CARE MCAID COORDINATED CARE MCAID 12.12 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0011A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0011A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MCAID MOLINA MCAID 12.73 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0011A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MCR ADV MOLINA MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0011A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0011A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0011A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0011A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0011A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0011A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0011A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0011A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0012A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0012A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AETNA MCR ADV AETNA MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0012A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 12.73 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0012A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 COORDINATED CARE MCAID COORDINATED CARE MCAID 12.12 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0012A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0012A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MCAID MOLINA MCAID 12.73 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0012A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MCR ADV MOLINA MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0012A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0012A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0012A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0012A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0012A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0012A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0012A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0012A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0013A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0013A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AETNA MCR ADV AETNA MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0013A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 12.73 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0013A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 COORDINATED CARE MCAID COORDINATED CARE MCAID 12.12 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0013A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0013A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MCAID MOLINA MCAID 12.73 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0013A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MCR ADV MOLINA MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0013A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0013A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0013A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0013A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0013A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0013A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0013A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0013A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0031A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0031A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AETNA MCR ADV AETNA MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0031A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 12.73 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0031A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 COORDINATED CARE MCAID COORDINATED CARE MCAID 12.12 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0031A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0031A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MCAID MOLINA MCAID 12.73 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0031A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MCR ADV MOLINA MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0031A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0031A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0031A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0031A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0031A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0031A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0031A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0031A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0041A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0041A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AETNA MCR ADV AETNA MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0041A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 12.73 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0041A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 COORDINATED CARE MCAID COORDINATED CARE MCAID 12.12 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0041A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0041A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MCAID MOLINA MCAID 12.73 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0041A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MCR ADV MOLINA MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0041A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0041A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0041A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0041A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0041A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0041A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0041A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0041A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0042A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0042A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AETNA MCR ADV AETNA MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0042A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 12.73 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0042A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 COORDINATED CARE MCAID COORDINATED CARE MCAID 12.12 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0042A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0042A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MCAID MOLINA MCAID 12.73 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0042A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MCR ADV MOLINA MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0042A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0042A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0042A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0042A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0042A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0042A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0042A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0042A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0051A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0051A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AETNA MCR ADV AETNA MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0051A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 12.73 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0051A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 COORDINATED CARE MCAID COORDINATED CARE MCAID 12.12 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0051A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0051A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MCAID MOLINA MCAID 12.73 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0051A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MCR ADV MOLINA MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0051A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0051A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0051A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0051A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0051A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0051A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0051A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0051A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0052A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0052A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AETNA MCR ADV AETNA MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0052A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 12.73 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0052A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 COORDINATED CARE MCAID COORDINATED CARE MCAID 12.12 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0052A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0052A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MCAID MOLINA MCAID 12.73 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0052A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MCR ADV MOLINA MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0052A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0052A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0052A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0052A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0052A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0052A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0052A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0052A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0053A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0053A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AETNA MCR ADV AETNA MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0053A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 12.73 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0053A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 COORDINATED CARE MCAID COORDINATED CARE MCAID 12.12 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0053A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0053A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MCAID MOLINA MCAID 12.73 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0053A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MCR ADV MOLINA MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0053A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0053A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0053A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0053A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0053A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0053A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0053A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0053A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0054A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0054A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AETNA MCR ADV AETNA MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0054A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 12.73 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0054A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 COORDINATED CARE MCAID COORDINATED CARE MCAID 12.12 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0054A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0054A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MCAID MOLINA MCAID 12.73 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0054A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MCR ADV MOLINA MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0054A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0054A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0054A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0054A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0054A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0054A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0054A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0054A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0064A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0064A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AETNA MCR ADV AETNA MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0064A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 12.73 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0064A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 COORDINATED CARE MCAID COORDINATED CARE MCAID 12.12 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0064A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0064A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MCAID MOLINA MCAID 12.73 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0064A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MCR ADV MOLINA MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0064A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0064A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0064A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0064A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0064A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0064A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0064A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0064A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0071A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0071A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AETNA MCR ADV AETNA MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0071A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 12.73 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0071A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 COORDINATED CARE MCAID COORDINATED CARE MCAID 12.12 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0071A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0071A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MCAID MOLINA MCAID 12.73 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0071A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MCR ADV MOLINA MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0071A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0071A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0071A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0071A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0071A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0071A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0071A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0071A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0072A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0072A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AETNA MCR ADV AETNA MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0072A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 12.73 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0072A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 COORDINATED CARE MCAID COORDINATED CARE MCAID 12.12 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0072A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0072A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MCAID MOLINA MCAID 12.73 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0072A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MCR ADV MOLINA MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0072A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0072A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0072A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0072A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0072A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0072A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 40 999999999 12.12 40 fee schedule "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0072A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 999999999 12.12 40 "IMMUNIZATION ADMINISTRATION BY INTRAMUSCULAR INJECTION OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, SINGLE DOSE" 0072A_3 CDM 960 RC 90480 HCPCS outpatient 40 30 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 40 999999999 12.12 40 fee schedule "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_1 CDM 360 RC 10060 HCPCS outpatient 319.11 239.33 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 287.2 999999999 248.91 303.15 case rate "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_1 CDM 360 RC 10060 HCPCS outpatient 319.11 239.33 AETNA MCR ADV AETNA MCR ADV 248.91 78 999999999 248.91 303.15 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_1 CDM 360 RC 10060 HCPCS outpatient 319.11 239.33 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 279.44 87.57 999999999 248.91 303.15 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_1 CDM 360 RC 10060 HCPCS outpatient 319.11 239.33 COORDINATED CARE MCAID COORDINATED CARE MCAID 271.47 85.07 999999999 248.91 303.15 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_1 CDM 360 RC 10060 HCPCS outpatient 319.11 239.33 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 271.47 85.07 999999999 248.91 303.15 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_1 CDM 360 RC 10060 HCPCS outpatient 319.11 239.33 MOLINA MCAID MOLINA MCAID 266.14 83.4 999999999 248.91 303.15 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_1 CDM 360 RC 10060 HCPCS outpatient 319.11 239.33 MOLINA MCR ADV MOLINA MCR ADV 284.01 89 999999999 248.91 303.15 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_1 CDM 360 RC 10060 HCPCS outpatient 319.11 239.33 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 284.01 89 999999999 248.91 303.15 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_1 CDM 360 RC 10060 HCPCS outpatient 319.11 239.33 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 284.01 89 999999999 248.91 303.15 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_1 CDM 360 RC 10060 HCPCS outpatient 319.11 239.33 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 287.2 90 999999999 248.91 303.15 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_1 CDM 360 RC 10060 HCPCS outpatient 319.11 239.33 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 303.15 95 999999999 248.91 303.15 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_1 CDM 360 RC 10060 HCPCS outpatient 319.11 239.33 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 303.15 95 999999999 248.91 303.15 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_1 CDM 360 RC 10060 HCPCS outpatient 319.11 239.33 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 284.01 89 999999999 248.91 303.15 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_1 CDM 360 RC 10060 HCPCS outpatient 319.11 239.33 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 280.82 88 999999999 248.91 303.15 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_1 CDM 360 RC 10060 HCPCS outpatient 319.11 239.33 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 284.01 89 999999999 248.91 303.15 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_2 CDM 360 RC 10060 HCPCS outpatient 319.11 239.33 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 287.2 999999999 248.91 303.15 case rate "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_2 CDM 360 RC 10060 HCPCS outpatient 319.11 239.33 AETNA MCR ADV AETNA MCR ADV 248.91 78 999999999 248.91 303.15 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_2 CDM 360 RC 10060 HCPCS outpatient 319.11 239.33 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 279.44 87.57 999999999 248.91 303.15 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_2 CDM 360 RC 10060 HCPCS outpatient 319.11 239.33 COORDINATED CARE MCAID COORDINATED CARE MCAID 271.47 85.07 999999999 248.91 303.15 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_2 CDM 360 RC 10060 HCPCS outpatient 319.11 239.33 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 271.47 85.07 999999999 248.91 303.15 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_2 CDM 360 RC 10060 HCPCS outpatient 319.11 239.33 MOLINA MCAID MOLINA MCAID 266.14 83.4 999999999 248.91 303.15 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_2 CDM 360 RC 10060 HCPCS outpatient 319.11 239.33 MOLINA MCR ADV MOLINA MCR ADV 284.01 89 999999999 248.91 303.15 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_2 CDM 360 RC 10060 HCPCS outpatient 319.11 239.33 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 284.01 89 999999999 248.91 303.15 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_2 CDM 360 RC 10060 HCPCS outpatient 319.11 239.33 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 284.01 89 999999999 248.91 303.15 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_2 CDM 360 RC 10060 HCPCS outpatient 319.11 239.33 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 287.2 90 999999999 248.91 303.15 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_2 CDM 360 RC 10060 HCPCS outpatient 319.11 239.33 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 303.15 95 999999999 248.91 303.15 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_2 CDM 360 RC 10060 HCPCS outpatient 319.11 239.33 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 303.15 95 999999999 248.91 303.15 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_2 CDM 360 RC 10060 HCPCS outpatient 319.11 239.33 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 284.01 89 999999999 248.91 303.15 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_2 CDM 360 RC 10060 HCPCS outpatient 319.11 239.33 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 280.82 88 999999999 248.91 303.15 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_2 CDM 360 RC 10060 HCPCS outpatient 319.11 239.33 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 284.01 89 999999999 248.91 303.15 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_3 CDM 360 RC 10060 HCPCS outpatient 256 192 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 230.4 999999999 199.68 243.2 case rate "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_3 CDM 360 RC 10060 HCPCS outpatient 256 192 AETNA MCR ADV AETNA MCR ADV 199.68 78 999999999 199.68 243.2 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_3 CDM 360 RC 10060 HCPCS outpatient 256 192 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 224.18 87.57 999999999 199.68 243.2 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_3 CDM 360 RC 10060 HCPCS outpatient 256 192 COORDINATED CARE MCAID COORDINATED CARE MCAID 217.78 85.07 999999999 199.68 243.2 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_3 CDM 360 RC 10060 HCPCS outpatient 256 192 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 217.78 85.07 999999999 199.68 243.2 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_3 CDM 360 RC 10060 HCPCS outpatient 256 192 MOLINA MCAID MOLINA MCAID 213.5 83.4 999999999 199.68 243.2 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_3 CDM 360 RC 10060 HCPCS outpatient 256 192 MOLINA MCR ADV MOLINA MCR ADV 227.84 89 999999999 199.68 243.2 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_3 CDM 360 RC 10060 HCPCS outpatient 256 192 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 227.84 89 999999999 199.68 243.2 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_3 CDM 360 RC 10060 HCPCS outpatient 256 192 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 227.84 89 999999999 199.68 243.2 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_3 CDM 360 RC 10060 HCPCS outpatient 256 192 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 230.4 90 999999999 199.68 243.2 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_3 CDM 360 RC 10060 HCPCS outpatient 256 192 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 243.2 95 999999999 199.68 243.2 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_3 CDM 360 RC 10060 HCPCS outpatient 256 192 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 243.2 95 999999999 199.68 243.2 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_3 CDM 360 RC 10060 HCPCS outpatient 256 192 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 227.84 89 999999999 199.68 243.2 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_3 CDM 360 RC 10060 HCPCS outpatient 256 192 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 225.28 88 999999999 199.68 243.2 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 10060_3 CDM 360 RC 10060 HCPCS outpatient 256 192 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 227.84 89 999999999 199.68 243.2 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_1 CDM 360 RC 10061 HCPCS outpatient 555.93 416.95 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 500.34 999999999 433.63 528.13 case rate "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_1 CDM 360 RC 10061 HCPCS outpatient 555.93 416.95 AETNA MCR ADV AETNA MCR ADV 433.63 78 999999999 433.63 528.13 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_1 CDM 360 RC 10061 HCPCS outpatient 555.93 416.95 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 486.83 87.57 999999999 433.63 528.13 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_1 CDM 360 RC 10061 HCPCS outpatient 555.93 416.95 COORDINATED CARE MCAID COORDINATED CARE MCAID 472.93 85.07 999999999 433.63 528.13 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_1 CDM 360 RC 10061 HCPCS outpatient 555.93 416.95 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 472.93 85.07 999999999 433.63 528.13 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_1 CDM 360 RC 10061 HCPCS outpatient 555.93 416.95 MOLINA MCAID MOLINA MCAID 463.65 83.4 999999999 433.63 528.13 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_1 CDM 360 RC 10061 HCPCS outpatient 555.93 416.95 MOLINA MCR ADV MOLINA MCR ADV 494.78 89 999999999 433.63 528.13 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_1 CDM 360 RC 10061 HCPCS outpatient 555.93 416.95 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 494.78 89 999999999 433.63 528.13 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_1 CDM 360 RC 10061 HCPCS outpatient 555.93 416.95 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 494.78 89 999999999 433.63 528.13 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_1 CDM 360 RC 10061 HCPCS outpatient 555.93 416.95 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 500.34 90 999999999 433.63 528.13 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_1 CDM 360 RC 10061 HCPCS outpatient 555.93 416.95 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 528.13 95 999999999 433.63 528.13 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_1 CDM 360 RC 10061 HCPCS outpatient 555.93 416.95 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 528.13 95 999999999 433.63 528.13 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_1 CDM 360 RC 10061 HCPCS outpatient 555.93 416.95 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 494.78 89 999999999 433.63 528.13 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_1 CDM 360 RC 10061 HCPCS outpatient 555.93 416.95 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 489.22 88 999999999 433.63 528.13 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_1 CDM 360 RC 10061 HCPCS outpatient 555.93 416.95 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 494.78 89 999999999 433.63 528.13 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_2 CDM 360 RC 10061 HCPCS outpatient 555.93 416.95 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 500.34 999999999 433.63 528.13 case rate "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_2 CDM 360 RC 10061 HCPCS outpatient 555.93 416.95 AETNA MCR ADV AETNA MCR ADV 433.63 78 999999999 433.63 528.13 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_2 CDM 360 RC 10061 HCPCS outpatient 555.93 416.95 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 486.83 87.57 999999999 433.63 528.13 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_2 CDM 360 RC 10061 HCPCS outpatient 555.93 416.95 COORDINATED CARE MCAID COORDINATED CARE MCAID 472.93 85.07 999999999 433.63 528.13 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_2 CDM 360 RC 10061 HCPCS outpatient 555.93 416.95 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 472.93 85.07 999999999 433.63 528.13 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_2 CDM 360 RC 10061 HCPCS outpatient 555.93 416.95 MOLINA MCAID MOLINA MCAID 463.65 83.4 999999999 433.63 528.13 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_2 CDM 360 RC 10061 HCPCS outpatient 555.93 416.95 MOLINA MCR ADV MOLINA MCR ADV 494.78 89 999999999 433.63 528.13 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_2 CDM 360 RC 10061 HCPCS outpatient 555.93 416.95 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 494.78 89 999999999 433.63 528.13 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_2 CDM 360 RC 10061 HCPCS outpatient 555.93 416.95 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 494.78 89 999999999 433.63 528.13 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_2 CDM 360 RC 10061 HCPCS outpatient 555.93 416.95 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 500.34 90 999999999 433.63 528.13 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_2 CDM 360 RC 10061 HCPCS outpatient 555.93 416.95 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 528.13 95 999999999 433.63 528.13 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_2 CDM 360 RC 10061 HCPCS outpatient 555.93 416.95 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 528.13 95 999999999 433.63 528.13 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_2 CDM 360 RC 10061 HCPCS outpatient 555.93 416.95 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 494.78 89 999999999 433.63 528.13 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_2 CDM 360 RC 10061 HCPCS outpatient 555.93 416.95 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 489.22 88 999999999 433.63 528.13 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_2 CDM 360 RC 10061 HCPCS outpatient 555.93 416.95 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 494.78 89 999999999 433.63 528.13 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_3 CDM 360 RC 10061 HCPCS outpatient 435 326.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 391.5 999999999 339.3 413.25 case rate "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_3 CDM 360 RC 10061 HCPCS outpatient 435 326.25 AETNA MCR ADV AETNA MCR ADV 339.3 78 999999999 339.3 413.25 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_3 CDM 360 RC 10061 HCPCS outpatient 435 326.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 380.93 87.57 999999999 339.3 413.25 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_3 CDM 360 RC 10061 HCPCS outpatient 435 326.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 370.05 85.07 999999999 339.3 413.25 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_3 CDM 360 RC 10061 HCPCS outpatient 435 326.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 370.05 85.07 999999999 339.3 413.25 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_3 CDM 360 RC 10061 HCPCS outpatient 435 326.25 MOLINA MCAID MOLINA MCAID 362.79 83.4 999999999 339.3 413.25 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_3 CDM 360 RC 10061 HCPCS outpatient 435 326.25 MOLINA MCR ADV MOLINA MCR ADV 387.15 89 999999999 339.3 413.25 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_3 CDM 360 RC 10061 HCPCS outpatient 435 326.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 387.15 89 999999999 339.3 413.25 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_3 CDM 360 RC 10061 HCPCS outpatient 435 326.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 387.15 89 999999999 339.3 413.25 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_3 CDM 360 RC 10061 HCPCS outpatient 435 326.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 391.5 90 999999999 339.3 413.25 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_3 CDM 360 RC 10061 HCPCS outpatient 435 326.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 413.25 95 999999999 339.3 413.25 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_3 CDM 360 RC 10061 HCPCS outpatient 435 326.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 413.25 95 999999999 339.3 413.25 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_3 CDM 360 RC 10061 HCPCS outpatient 435 326.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 387.15 89 999999999 339.3 413.25 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_3 CDM 360 RC 10061 HCPCS outpatient 435 326.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 382.8 88 999999999 339.3 413.25 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 10061_3 CDM 360 RC 10061 HCPCS outpatient 435 326.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 387.15 89 999999999 339.3 413.25 percent of total billed charges INCISION AND DRAINAGE OF PILONIDAL CYST; SIMPLE 10080_3 CDM 360 RC 10080 HCPCS outpatient 536 402 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 482.4 999999999 418.08 509.2 case rate INCISION AND DRAINAGE OF PILONIDAL CYST; SIMPLE 10080_3 CDM 360 RC 10080 HCPCS outpatient 536 402 AETNA MCR ADV AETNA MCR ADV 418.08 78 999999999 418.08 509.2 percent of total billed charges INCISION AND DRAINAGE OF PILONIDAL CYST; SIMPLE 10080_3 CDM 360 RC 10080 HCPCS outpatient 536 402 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 469.38 87.57 999999999 418.08 509.2 percent of total billed charges INCISION AND DRAINAGE OF PILONIDAL CYST; SIMPLE 10080_3 CDM 360 RC 10080 HCPCS outpatient 536 402 COORDINATED CARE MCAID COORDINATED CARE MCAID 455.98 85.07 999999999 418.08 509.2 percent of total billed charges INCISION AND DRAINAGE OF PILONIDAL CYST; SIMPLE 10080_3 CDM 360 RC 10080 HCPCS outpatient 536 402 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 455.98 85.07 999999999 418.08 509.2 percent of total billed charges INCISION AND DRAINAGE OF PILONIDAL CYST; SIMPLE 10080_3 CDM 360 RC 10080 HCPCS outpatient 536 402 MOLINA MCAID MOLINA MCAID 447.02 83.4 999999999 418.08 509.2 percent of total billed charges INCISION AND DRAINAGE OF PILONIDAL CYST; SIMPLE 10080_3 CDM 360 RC 10080 HCPCS outpatient 536 402 MOLINA MCR ADV MOLINA MCR ADV 477.04 89 999999999 418.08 509.2 percent of total billed charges INCISION AND DRAINAGE OF PILONIDAL CYST; SIMPLE 10080_3 CDM 360 RC 10080 HCPCS outpatient 536 402 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 477.04 89 999999999 418.08 509.2 percent of total billed charges INCISION AND DRAINAGE OF PILONIDAL CYST; SIMPLE 10080_3 CDM 360 RC 10080 HCPCS outpatient 536 402 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 477.04 89 999999999 418.08 509.2 percent of total billed charges INCISION AND DRAINAGE OF PILONIDAL CYST; SIMPLE 10080_3 CDM 360 RC 10080 HCPCS outpatient 536 402 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 482.4 90 999999999 418.08 509.2 percent of total billed charges INCISION AND DRAINAGE OF PILONIDAL CYST; SIMPLE 10080_3 CDM 360 RC 10080 HCPCS outpatient 536 402 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 509.2 95 999999999 418.08 509.2 percent of total billed charges INCISION AND DRAINAGE OF PILONIDAL CYST; SIMPLE 10080_3 CDM 360 RC 10080 HCPCS outpatient 536 402 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 509.2 95 999999999 418.08 509.2 percent of total billed charges INCISION AND DRAINAGE OF PILONIDAL CYST; SIMPLE 10080_3 CDM 360 RC 10080 HCPCS outpatient 536 402 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 477.04 89 999999999 418.08 509.2 percent of total billed charges INCISION AND DRAINAGE OF PILONIDAL CYST; SIMPLE 10080_3 CDM 360 RC 10080 HCPCS outpatient 536 402 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 471.68 88 999999999 418.08 509.2 percent of total billed charges INCISION AND DRAINAGE OF PILONIDAL CYST; SIMPLE 10080_3 CDM 360 RC 10080 HCPCS outpatient 536 402 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 477.04 89 999999999 418.08 509.2 percent of total billed charges "INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; SIMPLE" 10120_3 CDM 360 RC 10120 HCPCS outpatient 310 232.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 279 999999999 241.8 294.5 case rate "INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; SIMPLE" 10120_3 CDM 360 RC 10120 HCPCS outpatient 310 232.5 AETNA MCR ADV AETNA MCR ADV 241.8 78 999999999 241.8 294.5 percent of total billed charges "INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; SIMPLE" 10120_3 CDM 360 RC 10120 HCPCS outpatient 310 232.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 271.47 87.57 999999999 241.8 294.5 percent of total billed charges "INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; SIMPLE" 10120_3 CDM 360 RC 10120 HCPCS outpatient 310 232.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 263.72 85.07 999999999 241.8 294.5 percent of total billed charges "INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; SIMPLE" 10120_3 CDM 360 RC 10120 HCPCS outpatient 310 232.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 263.72 85.07 999999999 241.8 294.5 percent of total billed charges "INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; SIMPLE" 10120_3 CDM 360 RC 10120 HCPCS outpatient 310 232.5 MOLINA MCAID MOLINA MCAID 258.54 83.4 999999999 241.8 294.5 percent of total billed charges "INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; SIMPLE" 10120_3 CDM 360 RC 10120 HCPCS outpatient 310 232.5 MOLINA MCR ADV MOLINA MCR ADV 275.9 89 999999999 241.8 294.5 percent of total billed charges "INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; SIMPLE" 10120_3 CDM 360 RC 10120 HCPCS outpatient 310 232.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 275.9 89 999999999 241.8 294.5 percent of total billed charges "INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; SIMPLE" 10120_3 CDM 360 RC 10120 HCPCS outpatient 310 232.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 275.9 89 999999999 241.8 294.5 percent of total billed charges "INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; SIMPLE" 10120_3 CDM 360 RC 10120 HCPCS outpatient 310 232.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 279 90 999999999 241.8 294.5 percent of total billed charges "INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; SIMPLE" 10120_3 CDM 360 RC 10120 HCPCS outpatient 310 232.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 294.5 95 999999999 241.8 294.5 percent of total billed charges "INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; SIMPLE" 10120_3 CDM 360 RC 10120 HCPCS outpatient 310 232.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 294.5 95 999999999 241.8 294.5 percent of total billed charges "INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; SIMPLE" 10120_3 CDM 360 RC 10120 HCPCS outpatient 310 232.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 275.9 89 999999999 241.8 294.5 percent of total billed charges "INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; SIMPLE" 10120_3 CDM 360 RC 10120 HCPCS outpatient 310 232.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 272.8 88 999999999 241.8 294.5 percent of total billed charges "INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; SIMPLE" 10120_3 CDM 360 RC 10120 HCPCS outpatient 310 232.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 275.9 89 999999999 241.8 294.5 percent of total billed charges "INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; COMPLICATED" 10121_3 CDM 360 RC 10121 HCPCS outpatient 544 408 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 489.6 999999999 424.32 516.8 case rate "INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; COMPLICATED" 10121_3 CDM 360 RC 10121 HCPCS outpatient 544 408 AETNA MCR ADV AETNA MCR ADV 424.32 78 999999999 424.32 516.8 percent of total billed charges "INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; COMPLICATED" 10121_3 CDM 360 RC 10121 HCPCS outpatient 544 408 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 476.38 87.57 999999999 424.32 516.8 percent of total billed charges "INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; COMPLICATED" 10121_3 CDM 360 RC 10121 HCPCS outpatient 544 408 COORDINATED CARE MCAID COORDINATED CARE MCAID 462.78 85.07 999999999 424.32 516.8 percent of total billed charges "INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; COMPLICATED" 10121_3 CDM 360 RC 10121 HCPCS outpatient 544 408 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 462.78 85.07 999999999 424.32 516.8 percent of total billed charges "INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; COMPLICATED" 10121_3 CDM 360 RC 10121 HCPCS outpatient 544 408 MOLINA MCAID MOLINA MCAID 453.7 83.4 999999999 424.32 516.8 percent of total billed charges "INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; COMPLICATED" 10121_3 CDM 360 RC 10121 HCPCS outpatient 544 408 MOLINA MCR ADV MOLINA MCR ADV 484.16 89 999999999 424.32 516.8 percent of total billed charges "INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; COMPLICATED" 10121_3 CDM 360 RC 10121 HCPCS outpatient 544 408 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 484.16 89 999999999 424.32 516.8 percent of total billed charges "INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; COMPLICATED" 10121_3 CDM 360 RC 10121 HCPCS outpatient 544 408 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 484.16 89 999999999 424.32 516.8 percent of total billed charges "INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; COMPLICATED" 10121_3 CDM 360 RC 10121 HCPCS outpatient 544 408 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 489.6 90 999999999 424.32 516.8 percent of total billed charges "INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; COMPLICATED" 10121_3 CDM 360 RC 10121 HCPCS outpatient 544 408 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 516.8 95 999999999 424.32 516.8 percent of total billed charges "INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; COMPLICATED" 10121_3 CDM 360 RC 10121 HCPCS outpatient 544 408 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 516.8 95 999999999 424.32 516.8 percent of total billed charges "INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; COMPLICATED" 10121_3 CDM 360 RC 10121 HCPCS outpatient 544 408 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 484.16 89 999999999 424.32 516.8 percent of total billed charges "INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; COMPLICATED" 10121_3 CDM 360 RC 10121 HCPCS outpatient 544 408 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 478.72 88 999999999 424.32 516.8 percent of total billed charges "INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; COMPLICATED" 10121_3 CDM 360 RC 10121 HCPCS outpatient 544 408 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 484.16 89 999999999 424.32 516.8 percent of total billed charges "INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR FLUID COLLECTION" 10140_3 CDM 360 RC 10140 HCPCS outpatient 351 263.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 315.9 999999999 273.78 333.45 case rate "INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR FLUID COLLECTION" 10140_3 CDM 360 RC 10140 HCPCS outpatient 351 263.25 AETNA MCR ADV AETNA MCR ADV 273.78 78 999999999 273.78 333.45 percent of total billed charges "INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR FLUID COLLECTION" 10140_3 CDM 360 RC 10140 HCPCS outpatient 351 263.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 307.37 87.57 999999999 273.78 333.45 percent of total billed charges "INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR FLUID COLLECTION" 10140_3 CDM 360 RC 10140 HCPCS outpatient 351 263.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 298.6 85.07 999999999 273.78 333.45 percent of total billed charges "INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR FLUID COLLECTION" 10140_3 CDM 360 RC 10140 HCPCS outpatient 351 263.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 298.6 85.07 999999999 273.78 333.45 percent of total billed charges "INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR FLUID COLLECTION" 10140_3 CDM 360 RC 10140 HCPCS outpatient 351 263.25 MOLINA MCAID MOLINA MCAID 292.73 83.4 999999999 273.78 333.45 percent of total billed charges "INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR FLUID COLLECTION" 10140_3 CDM 360 RC 10140 HCPCS outpatient 351 263.25 MOLINA MCR ADV MOLINA MCR ADV 312.39 89 999999999 273.78 333.45 percent of total billed charges "INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR FLUID COLLECTION" 10140_3 CDM 360 RC 10140 HCPCS outpatient 351 263.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 312.39 89 999999999 273.78 333.45 percent of total billed charges "INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR FLUID COLLECTION" 10140_3 CDM 360 RC 10140 HCPCS outpatient 351 263.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 312.39 89 999999999 273.78 333.45 percent of total billed charges "INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR FLUID COLLECTION" 10140_3 CDM 360 RC 10140 HCPCS outpatient 351 263.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 315.9 90 999999999 273.78 333.45 percent of total billed charges "INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR FLUID COLLECTION" 10140_3 CDM 360 RC 10140 HCPCS outpatient 351 263.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 333.45 95 999999999 273.78 333.45 percent of total billed charges "INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR FLUID COLLECTION" 10140_3 CDM 360 RC 10140 HCPCS outpatient 351 263.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 333.45 95 999999999 273.78 333.45 percent of total billed charges "INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR FLUID COLLECTION" 10140_3 CDM 360 RC 10140 HCPCS outpatient 351 263.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 312.39 89 999999999 273.78 333.45 percent of total billed charges "INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR FLUID COLLECTION" 10140_3 CDM 360 RC 10140 HCPCS outpatient 351 263.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 308.88 88 999999999 273.78 333.45 percent of total billed charges "INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR FLUID COLLECTION" 10140_3 CDM 360 RC 10140 HCPCS outpatient 351 263.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 312.39 89 999999999 273.78 333.45 percent of total billed charges "PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST" 10160_3 CDM 361 RC 10160 HCPCS outpatient 266 199.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 239.4 999999999 207.48 252.7 case rate "PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST" 10160_3 CDM 361 RC 10160 HCPCS outpatient 266 199.5 AETNA MCR ADV AETNA MCR ADV 207.48 78 999999999 207.48 252.7 percent of total billed charges "PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST" 10160_3 CDM 361 RC 10160 HCPCS outpatient 266 199.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 232.94 87.57 999999999 207.48 252.7 percent of total billed charges "PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST" 10160_3 CDM 361 RC 10160 HCPCS outpatient 266 199.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 226.29 85.07 999999999 207.48 252.7 percent of total billed charges "PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST" 10160_3 CDM 361 RC 10160 HCPCS outpatient 266 199.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 226.29 85.07 999999999 207.48 252.7 percent of total billed charges "PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST" 10160_3 CDM 361 RC 10160 HCPCS outpatient 266 199.5 MOLINA MCAID MOLINA MCAID 221.84 83.4 999999999 207.48 252.7 percent of total billed charges "PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST" 10160_3 CDM 361 RC 10160 HCPCS outpatient 266 199.5 MOLINA MCR ADV MOLINA MCR ADV 236.74 89 999999999 207.48 252.7 percent of total billed charges "PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST" 10160_3 CDM 361 RC 10160 HCPCS outpatient 266 199.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 236.74 89 999999999 207.48 252.7 percent of total billed charges "PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST" 10160_3 CDM 361 RC 10160 HCPCS outpatient 266 199.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 236.74 89 999999999 207.48 252.7 percent of total billed charges "PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST" 10160_3 CDM 361 RC 10160 HCPCS outpatient 266 199.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 239.4 90 999999999 207.48 252.7 percent of total billed charges "PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST" 10160_3 CDM 361 RC 10160 HCPCS outpatient 266 199.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 252.7 95 999999999 207.48 252.7 percent of total billed charges "PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST" 10160_3 CDM 361 RC 10160 HCPCS outpatient 266 199.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 252.7 95 999999999 207.48 252.7 percent of total billed charges "PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST" 10160_3 CDM 361 RC 10160 HCPCS outpatient 266 199.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 236.74 89 999999999 207.48 252.7 percent of total billed charges "PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST" 10160_3 CDM 361 RC 10160 HCPCS outpatient 266 199.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 234.08 88 999999999 207.48 252.7 percent of total billed charges "PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST" 10160_3 CDM 361 RC 10160 HCPCS outpatient 266 199.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 236.74 89 999999999 207.48 252.7 percent of total billed charges P PHYS APP/REJECT MOD JOB OFFER 1038M_3 CDM 981 RC 1038M HCPCS outpatient 89 66.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 999999999 89 93.45 P PHYS APP/REJECT MOD JOB OFFER 1038M_3 CDM 981 RC 1038M HCPCS outpatient 89 66.75 AETNA MCR ADV AETNA MCR ADV 89 999999999 89 93.45 fee schedule P PHYS APP/REJECT MOD JOB OFFER 1038M_3 CDM 981 RC 1038M HCPCS outpatient 89 66.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 93.45 999999999 89 93.45 fee schedule P PHYS APP/REJECT MOD JOB OFFER 1038M_3 CDM 981 RC 1038M HCPCS outpatient 89 66.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 89 999999999 89 93.45 fee schedule P PHYS APP/REJECT MOD JOB OFFER 1038M_3 CDM 981 RC 1038M HCPCS outpatient 89 66.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 89 999999999 89 93.45 fee schedule P PHYS APP/REJECT MOD JOB OFFER 1038M_3 CDM 981 RC 1038M HCPCS outpatient 89 66.75 MOLINA MCAID MOLINA MCAID 93.45 999999999 89 93.45 fee schedule P PHYS APP/REJECT MOD JOB OFFER 1038M_3 CDM 981 RC 1038M HCPCS outpatient 89 66.75 MOLINA MCR ADV MOLINA MCR ADV 89 999999999 89 93.45 fee schedule P PHYS APP/REJECT MOD JOB OFFER 1038M_3 CDM 981 RC 1038M HCPCS outpatient 89 66.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 89 999999999 89 93.45 fee schedule P PHYS APP/REJECT MOD JOB OFFER 1038M_3 CDM 981 RC 1038M HCPCS outpatient 89 66.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 89 999999999 89 93.45 fee schedule P PHYS APP/REJECT MOD JOB OFFER 1038M_3 CDM 981 RC 1038M HCPCS outpatient 89 66.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 999999999 89 93.45 P PHYS APP/REJECT MOD JOB OFFER 1038M_3 CDM 981 RC 1038M HCPCS outpatient 89 66.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 999999999 89 93.45 P PHYS APP/REJECT MOD JOB OFFER 1038M_3 CDM 981 RC 1038M HCPCS outpatient 89 66.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 999999999 89 93.45 P PHYS APP/REJECT MOD JOB OFFER 1038M_3 CDM 981 RC 1038M HCPCS outpatient 89 66.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 89 999999999 89 93.45 fee schedule P PHYS APP/REJECT MOD JOB OFFER 1038M_3 CDM 981 RC 1038M HCPCS outpatient 89 66.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 999999999 89 93.45 P PHYS APP/REJECT MOD JOB OFFER 1038M_3 CDM 981 RC 1038M HCPCS outpatient 89 66.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 89 999999999 89 93.45 fee schedule PR L & I REPORT 1040M_3 CDM 981 RC 1040M HCPCS outpatient 82 61.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 999999999 82 86.1 PR L & I REPORT 1040M_3 CDM 981 RC 1040M HCPCS outpatient 82 61.5 AETNA MCR ADV AETNA MCR ADV 82 999999999 82 86.1 fee schedule PR L & I REPORT 1040M_3 CDM 981 RC 1040M HCPCS outpatient 82 61.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 86.1 999999999 82 86.1 fee schedule PR L & I REPORT 1040M_3 CDM 981 RC 1040M HCPCS outpatient 82 61.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 82 999999999 82 86.1 fee schedule PR L & I REPORT 1040M_3 CDM 981 RC 1040M HCPCS outpatient 82 61.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 82 999999999 82 86.1 fee schedule PR L & I REPORT 1040M_3 CDM 981 RC 1040M HCPCS outpatient 82 61.5 MOLINA MCAID MOLINA MCAID 86.1 999999999 82 86.1 fee schedule PR L & I REPORT 1040M_3 CDM 981 RC 1040M HCPCS outpatient 82 61.5 MOLINA MCR ADV MOLINA MCR ADV 82 999999999 82 86.1 fee schedule PR L & I REPORT 1040M_3 CDM 981 RC 1040M HCPCS outpatient 82 61.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 82 999999999 82 86.1 fee schedule PR L & I REPORT 1040M_3 CDM 981 RC 1040M HCPCS outpatient 82 61.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 82 999999999 82 86.1 fee schedule PR L & I REPORT 1040M_3 CDM 981 RC 1040M HCPCS outpatient 82 61.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 999999999 82 86.1 PR L & I REPORT 1040M_3 CDM 981 RC 1040M HCPCS outpatient 82 61.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 999999999 82 86.1 PR L & I REPORT 1040M_3 CDM 981 RC 1040M HCPCS outpatient 82 61.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 999999999 82 86.1 PR L & I REPORT 1040M_3 CDM 981 RC 1040M HCPCS outpatient 82 61.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 82 999999999 82 86.1 fee schedule PR L & I REPORT 1040M_3 CDM 981 RC 1040M HCPCS outpatient 82 61.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 999999999 82 86.1 PR L & I REPORT 1040M_3 CDM 981 RC 1040M HCPCS outpatient 82 61.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 82 999999999 82 86.1 fee schedule PR REOPEN DLI CLAIM 1041M_3 CDM 981 RC 1041M HCPCS outpatient 55 41.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 999999999 55 57.75 PR REOPEN DLI CLAIM 1041M_3 CDM 981 RC 1041M HCPCS outpatient 55 41.25 AETNA MCR ADV AETNA MCR ADV 55 999999999 55 57.75 fee schedule PR REOPEN DLI CLAIM 1041M_3 CDM 981 RC 1041M HCPCS outpatient 55 41.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 57.75 999999999 55 57.75 fee schedule PR REOPEN DLI CLAIM 1041M_3 CDM 981 RC 1041M HCPCS outpatient 55 41.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 55 999999999 55 57.75 fee schedule PR REOPEN DLI CLAIM 1041M_3 CDM 981 RC 1041M HCPCS outpatient 55 41.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 55 999999999 55 57.75 fee schedule PR REOPEN DLI CLAIM 1041M_3 CDM 981 RC 1041M HCPCS outpatient 55 41.25 MOLINA MCAID MOLINA MCAID 57.75 999999999 55 57.75 fee schedule PR REOPEN DLI CLAIM 1041M_3 CDM 981 RC 1041M HCPCS outpatient 55 41.25 MOLINA MCR ADV MOLINA MCR ADV 55 999999999 55 57.75 fee schedule PR REOPEN DLI CLAIM 1041M_3 CDM 981 RC 1041M HCPCS outpatient 55 41.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 55 999999999 55 57.75 fee schedule PR REOPEN DLI CLAIM 1041M_3 CDM 981 RC 1041M HCPCS outpatient 55 41.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 55 999999999 55 57.75 fee schedule PR REOPEN DLI CLAIM 1041M_3 CDM 981 RC 1041M HCPCS outpatient 55 41.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 999999999 55 57.75 PR REOPEN DLI CLAIM 1041M_3 CDM 981 RC 1041M HCPCS outpatient 55 41.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 999999999 55 57.75 PR REOPEN DLI CLAIM 1041M_3 CDM 981 RC 1041M HCPCS outpatient 55 41.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 999999999 55 57.75 PR REOPEN DLI CLAIM 1041M_3 CDM 981 RC 1041M HCPCS outpatient 55 41.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 55 999999999 55 57.75 fee schedule PR REOPEN DLI CLAIM 1041M_3 CDM 981 RC 1041M HCPCS outpatient 55 41.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 999999999 55 57.75 PR REOPEN DLI CLAIM 1041M_3 CDM 981 RC 1041M HCPCS outpatient 55 41.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 55 999999999 55 57.75 fee schedule PR INSURER ACTIVITY PRESC FORM 1073M_3 CDM 920 RC 1073M HCPCS outpatient 65 48.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 58.5 999999999 50.7 61.75 case rate PR INSURER ACTIVITY PRESC FORM 1073M_3 CDM 920 RC 1073M HCPCS outpatient 65 48.75 AETNA MCR ADV AETNA MCR ADV 50.7 78 999999999 50.7 61.75 percent of total billed charges PR INSURER ACTIVITY PRESC FORM 1073M_3 CDM 920 RC 1073M HCPCS outpatient 65 48.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 56.92 87.57 999999999 50.7 61.75 percent of total billed charges PR INSURER ACTIVITY PRESC FORM 1073M_3 CDM 920 RC 1073M HCPCS outpatient 65 48.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 55.3 85.07 999999999 50.7 61.75 percent of total billed charges PR INSURER ACTIVITY PRESC FORM 1073M_3 CDM 920 RC 1073M HCPCS outpatient 65 48.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 55.3 85.07 999999999 50.7 61.75 percent of total billed charges PR INSURER ACTIVITY PRESC FORM 1073M_3 CDM 920 RC 1073M HCPCS outpatient 65 48.75 MOLINA MCAID MOLINA MCAID 54.21 83.4 999999999 50.7 61.75 percent of total billed charges PR INSURER ACTIVITY PRESC FORM 1073M_3 CDM 920 RC 1073M HCPCS outpatient 65 48.75 MOLINA MCR ADV MOLINA MCR ADV 57.85 89 999999999 50.7 61.75 percent of total billed charges PR INSURER ACTIVITY PRESC FORM 1073M_3 CDM 920 RC 1073M HCPCS outpatient 65 48.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 57.85 89 999999999 50.7 61.75 percent of total billed charges PR INSURER ACTIVITY PRESC FORM 1073M_3 CDM 920 RC 1073M HCPCS outpatient 65 48.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 57.85 89 999999999 50.7 61.75 percent of total billed charges PR INSURER ACTIVITY PRESC FORM 1073M_3 CDM 920 RC 1073M HCPCS outpatient 65 48.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 58.5 90 999999999 50.7 61.75 percent of total billed charges PR INSURER ACTIVITY PRESC FORM 1073M_3 CDM 920 RC 1073M HCPCS outpatient 65 48.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 61.75 95 999999999 50.7 61.75 percent of total billed charges PR INSURER ACTIVITY PRESC FORM 1073M_3 CDM 920 RC 1073M HCPCS outpatient 65 48.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 61.75 95 999999999 50.7 61.75 percent of total billed charges PR INSURER ACTIVITY PRESC FORM 1073M_3 CDM 920 RC 1073M HCPCS outpatient 65 48.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 57.85 89 999999999 50.7 61.75 percent of total billed charges PR INSURER ACTIVITY PRESC FORM 1073M_3 CDM 920 RC 1073M HCPCS outpatient 65 48.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 57.2 88 999999999 50.7 61.75 percent of total billed charges PR INSURER ACTIVITY PRESC FORM 1073M_3 CDM 920 RC 1073M HCPCS outpatient 65 48.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 57.85 89 999999999 50.7 61.75 percent of total billed charges DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SKIN; UP TO 10% OF BODY SURFACE 11000_3 CDM 360 RC 11000 HCPCS outpatient 120 90 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 108 999999999 93.6 114 case rate DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SKIN; UP TO 10% OF BODY SURFACE 11000_3 CDM 360 RC 11000 HCPCS outpatient 120 90 AETNA MCR ADV AETNA MCR ADV 93.6 78 999999999 93.6 114 percent of total billed charges DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SKIN; UP TO 10% OF BODY SURFACE 11000_3 CDM 360 RC 11000 HCPCS outpatient 120 90 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 105.08 87.57 999999999 93.6 114 percent of total billed charges DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SKIN; UP TO 10% OF BODY SURFACE 11000_3 CDM 360 RC 11000 HCPCS outpatient 120 90 COORDINATED CARE MCAID COORDINATED CARE MCAID 102.08 85.07 999999999 93.6 114 percent of total billed charges DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SKIN; UP TO 10% OF BODY SURFACE 11000_3 CDM 360 RC 11000 HCPCS outpatient 120 90 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 102.08 85.07 999999999 93.6 114 percent of total billed charges DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SKIN; UP TO 10% OF BODY SURFACE 11000_3 CDM 360 RC 11000 HCPCS outpatient 120 90 MOLINA MCAID MOLINA MCAID 100.08 83.4 999999999 93.6 114 percent of total billed charges DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SKIN; UP TO 10% OF BODY SURFACE 11000_3 CDM 360 RC 11000 HCPCS outpatient 120 90 MOLINA MCR ADV MOLINA MCR ADV 106.8 89 999999999 93.6 114 percent of total billed charges DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SKIN; UP TO 10% OF BODY SURFACE 11000_3 CDM 360 RC 11000 HCPCS outpatient 120 90 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 106.8 89 999999999 93.6 114 percent of total billed charges DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SKIN; UP TO 10% OF BODY SURFACE 11000_3 CDM 360 RC 11000 HCPCS outpatient 120 90 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 106.8 89 999999999 93.6 114 percent of total billed charges DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SKIN; UP TO 10% OF BODY SURFACE 11000_3 CDM 360 RC 11000 HCPCS outpatient 120 90 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 108 90 999999999 93.6 114 percent of total billed charges DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SKIN; UP TO 10% OF BODY SURFACE 11000_3 CDM 360 RC 11000 HCPCS outpatient 120 90 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 114 95 999999999 93.6 114 percent of total billed charges DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SKIN; UP TO 10% OF BODY SURFACE 11000_3 CDM 360 RC 11000 HCPCS outpatient 120 90 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 114 95 999999999 93.6 114 percent of total billed charges DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SKIN; UP TO 10% OF BODY SURFACE 11000_3 CDM 360 RC 11000 HCPCS outpatient 120 90 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 106.8 89 999999999 93.6 114 percent of total billed charges DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SKIN; UP TO 10% OF BODY SURFACE 11000_3 CDM 360 RC 11000 HCPCS outpatient 120 90 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 105.6 88 999999999 93.6 114 percent of total billed charges DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SKIN; UP TO 10% OF BODY SURFACE 11000_3 CDM 360 RC 11000 HCPCS outpatient 120 90 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 106.8 89 999999999 93.6 114 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 1100000003_1 CDM 110 RC inpatient 2030 1522.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1827 90 999999999 1786.4 10619 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 1100000003_1 CDM 110 RC inpatient 2030 1522.5 AETNA MCR ADV AETNA MCR ADV 10619 999999999 1786.4 10619 per diem ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 1100000003_1 CDM 110 RC inpatient 2030 1522.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 3786.76 186.54 999999999 1786.4 10619 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 1100000003_1 CDM 110 RC inpatient 2030 1522.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 3678.56 181.21 999999999 1786.4 10619 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 1100000003_1 CDM 110 RC inpatient 2030 1522.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 3678.56 181.21 999999999 1786.4 10619 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 1100000003_1 CDM 110 RC inpatient 2030 1522.5 MOLINA MCAID MOLINA MCAID 3606.5 177.66 999999999 1786.4 10619 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 1100000003_1 CDM 110 RC inpatient 2030 1522.5 MOLINA MCR ADV MOLINA MCR ADV 8243 999999999 1786.4 10619 per diem ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 1100000003_1 CDM 110 RC inpatient 2030 1522.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 8243 999999999 1786.4 10619 per diem ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 1100000003_1 CDM 110 RC inpatient 2030 1522.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 8243 999999999 1786.4 10619 per diem ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 1100000003_1 CDM 110 RC inpatient 2030 1522.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1827 90 999999999 1786.4 10619 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 1100000003_1 CDM 110 RC inpatient 2030 1522.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1928.5 95 999999999 1786.4 10619 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 1100000003_1 CDM 110 RC inpatient 2030 1522.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1928.5 95 999999999 1786.4 10619 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 1100000003_1 CDM 110 RC inpatient 2030 1522.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 8243 999999999 1786.4 10619 per diem ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 1100000003_1 CDM 110 RC inpatient 2030 1522.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1786.4 88 999999999 1786.4 10619 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 1100000003_1 CDM 110 RC inpatient 2030 1522.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 7006.55 999999999 1786.4 10619 per diem "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 11042_1 CDM 360 RC 11042 HCPCS outpatient 180.45 135.34 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 162.41 999999999 140.75 171.43 case rate "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 11042_1 CDM 360 RC 11042 HCPCS outpatient 180.45 135.34 AETNA MCR ADV AETNA MCR ADV 140.75 78 999999999 140.75 171.43 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 11042_1 CDM 360 RC 11042 HCPCS outpatient 180.45 135.34 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 158.02 87.57 999999999 140.75 171.43 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 11042_1 CDM 360 RC 11042 HCPCS outpatient 180.45 135.34 COORDINATED CARE MCAID COORDINATED CARE MCAID 153.51 85.07 999999999 140.75 171.43 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 11042_1 CDM 360 RC 11042 HCPCS outpatient 180.45 135.34 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 153.51 85.07 999999999 140.75 171.43 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 11042_1 CDM 360 RC 11042 HCPCS outpatient 180.45 135.34 MOLINA MCAID MOLINA MCAID 150.5 83.4 999999999 140.75 171.43 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 11042_1 CDM 360 RC 11042 HCPCS outpatient 180.45 135.34 MOLINA MCR ADV MOLINA MCR ADV 160.6 89 999999999 140.75 171.43 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 11042_1 CDM 360 RC 11042 HCPCS outpatient 180.45 135.34 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 160.6 89 999999999 140.75 171.43 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 11042_1 CDM 360 RC 11042 HCPCS outpatient 180.45 135.34 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 160.6 89 999999999 140.75 171.43 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 11042_1 CDM 360 RC 11042 HCPCS outpatient 180.45 135.34 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 162.41 90 999999999 140.75 171.43 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 11042_1 CDM 360 RC 11042 HCPCS outpatient 180.45 135.34 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 171.43 95 999999999 140.75 171.43 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 11042_1 CDM 360 RC 11042 HCPCS outpatient 180.45 135.34 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 171.43 95 999999999 140.75 171.43 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 11042_1 CDM 360 RC 11042 HCPCS outpatient 180.45 135.34 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 160.6 89 999999999 140.75 171.43 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 11042_1 CDM 360 RC 11042 HCPCS outpatient 180.45 135.34 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 158.8 88 999999999 140.75 171.43 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 11042_1 CDM 360 RC 11042 HCPCS outpatient 180.45 135.34 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 160.6 89 999999999 140.75 171.43 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 11042_3 CDM 360 RC 11042 HCPCS outpatient 268 201 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 241.2 999999999 209.04 254.6 case rate "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 11042_3 CDM 360 RC 11042 HCPCS outpatient 268 201 AETNA MCR ADV AETNA MCR ADV 209.04 78 999999999 209.04 254.6 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 11042_3 CDM 360 RC 11042 HCPCS outpatient 268 201 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 234.69 87.57 999999999 209.04 254.6 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 11042_3 CDM 360 RC 11042 HCPCS outpatient 268 201 COORDINATED CARE MCAID COORDINATED CARE MCAID 227.99 85.07 999999999 209.04 254.6 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 11042_3 CDM 360 RC 11042 HCPCS outpatient 268 201 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 227.99 85.07 999999999 209.04 254.6 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 11042_3 CDM 360 RC 11042 HCPCS outpatient 268 201 MOLINA MCAID MOLINA MCAID 223.51 83.4 999999999 209.04 254.6 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 11042_3 CDM 360 RC 11042 HCPCS outpatient 268 201 MOLINA MCR ADV MOLINA MCR ADV 238.52 89 999999999 209.04 254.6 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 11042_3 CDM 360 RC 11042 HCPCS outpatient 268 201 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 238.52 89 999999999 209.04 254.6 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 11042_3 CDM 360 RC 11042 HCPCS outpatient 268 201 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 238.52 89 999999999 209.04 254.6 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 11042_3 CDM 360 RC 11042 HCPCS outpatient 268 201 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 241.2 90 999999999 209.04 254.6 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 11042_3 CDM 360 RC 11042 HCPCS outpatient 268 201 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 254.6 95 999999999 209.04 254.6 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 11042_3 CDM 360 RC 11042 HCPCS outpatient 268 201 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 254.6 95 999999999 209.04 254.6 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 11042_3 CDM 360 RC 11042 HCPCS outpatient 268 201 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 238.52 89 999999999 209.04 254.6 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 11042_3 CDM 360 RC 11042 HCPCS outpatient 268 201 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 235.84 88 999999999 209.04 254.6 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 11042_3 CDM 360 RC 11042 HCPCS outpatient 268 201 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 238.52 89 999999999 209.04 254.6 percent of total billed charges "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); SINGLE LESION" 11055_3 CDM 360 RC 11055 HCPCS outpatient 151 113.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 135.9 999999999 117.78 143.45 case rate "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); SINGLE LESION" 11055_3 CDM 360 RC 11055 HCPCS outpatient 151 113.25 AETNA MCR ADV AETNA MCR ADV 117.78 78 999999999 117.78 143.45 percent of total billed charges "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); SINGLE LESION" 11055_3 CDM 360 RC 11055 HCPCS outpatient 151 113.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 132.23 87.57 999999999 117.78 143.45 percent of total billed charges "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); SINGLE LESION" 11055_3 CDM 360 RC 11055 HCPCS outpatient 151 113.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 128.46 85.07 999999999 117.78 143.45 percent of total billed charges "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); SINGLE LESION" 11055_3 CDM 360 RC 11055 HCPCS outpatient 151 113.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 128.46 85.07 999999999 117.78 143.45 percent of total billed charges "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); SINGLE LESION" 11055_3 CDM 360 RC 11055 HCPCS outpatient 151 113.25 MOLINA MCAID MOLINA MCAID 125.93 83.4 999999999 117.78 143.45 percent of total billed charges "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); SINGLE LESION" 11055_3 CDM 360 RC 11055 HCPCS outpatient 151 113.25 MOLINA MCR ADV MOLINA MCR ADV 134.39 89 999999999 117.78 143.45 percent of total billed charges "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); SINGLE LESION" 11055_3 CDM 360 RC 11055 HCPCS outpatient 151 113.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 134.39 89 999999999 117.78 143.45 percent of total billed charges "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); SINGLE LESION" 11055_3 CDM 360 RC 11055 HCPCS outpatient 151 113.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 134.39 89 999999999 117.78 143.45 percent of total billed charges "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); SINGLE LESION" 11055_3 CDM 360 RC 11055 HCPCS outpatient 151 113.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 135.9 90 999999999 117.78 143.45 percent of total billed charges "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); SINGLE LESION" 11055_3 CDM 360 RC 11055 HCPCS outpatient 151 113.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 143.45 95 999999999 117.78 143.45 percent of total billed charges "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); SINGLE LESION" 11055_3 CDM 360 RC 11055 HCPCS outpatient 151 113.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 143.45 95 999999999 117.78 143.45 percent of total billed charges "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); SINGLE LESION" 11055_3 CDM 360 RC 11055 HCPCS outpatient 151 113.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 134.39 89 999999999 117.78 143.45 percent of total billed charges "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); SINGLE LESION" 11055_3 CDM 360 RC 11055 HCPCS outpatient 151 113.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 132.88 88 999999999 117.78 143.45 percent of total billed charges "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); SINGLE LESION" 11055_3 CDM 360 RC 11055 HCPCS outpatient 151 113.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 134.39 89 999999999 117.78 143.45 percent of total billed charges "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); 2 TO 4 LESIONS" 11056_3 CDM 360 RC 11056 HCPCS outpatient 172 129 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 154.8 999999999 134.16 163.4 case rate "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); 2 TO 4 LESIONS" 11056_3 CDM 360 RC 11056 HCPCS outpatient 172 129 AETNA MCR ADV AETNA MCR ADV 134.16 78 999999999 134.16 163.4 percent of total billed charges "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); 2 TO 4 LESIONS" 11056_3 CDM 360 RC 11056 HCPCS outpatient 172 129 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 150.62 87.57 999999999 134.16 163.4 percent of total billed charges "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); 2 TO 4 LESIONS" 11056_3 CDM 360 RC 11056 HCPCS outpatient 172 129 COORDINATED CARE MCAID COORDINATED CARE MCAID 146.32 85.07 999999999 134.16 163.4 percent of total billed charges "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); 2 TO 4 LESIONS" 11056_3 CDM 360 RC 11056 HCPCS outpatient 172 129 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 146.32 85.07 999999999 134.16 163.4 percent of total billed charges "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); 2 TO 4 LESIONS" 11056_3 CDM 360 RC 11056 HCPCS outpatient 172 129 MOLINA MCAID MOLINA MCAID 143.45 83.4 999999999 134.16 163.4 percent of total billed charges "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); 2 TO 4 LESIONS" 11056_3 CDM 360 RC 11056 HCPCS outpatient 172 129 MOLINA MCR ADV MOLINA MCR ADV 153.08 89 999999999 134.16 163.4 percent of total billed charges "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); 2 TO 4 LESIONS" 11056_3 CDM 360 RC 11056 HCPCS outpatient 172 129 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 153.08 89 999999999 134.16 163.4 percent of total billed charges "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); 2 TO 4 LESIONS" 11056_3 CDM 360 RC 11056 HCPCS outpatient 172 129 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 153.08 89 999999999 134.16 163.4 percent of total billed charges "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); 2 TO 4 LESIONS" 11056_3 CDM 360 RC 11056 HCPCS outpatient 172 129 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 154.8 90 999999999 134.16 163.4 percent of total billed charges "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); 2 TO 4 LESIONS" 11056_3 CDM 360 RC 11056 HCPCS outpatient 172 129 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 163.4 95 999999999 134.16 163.4 percent of total billed charges "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); 2 TO 4 LESIONS" 11056_3 CDM 360 RC 11056 HCPCS outpatient 172 129 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 163.4 95 999999999 134.16 163.4 percent of total billed charges "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); 2 TO 4 LESIONS" 11056_3 CDM 360 RC 11056 HCPCS outpatient 172 129 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 153.08 89 999999999 134.16 163.4 percent of total billed charges "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); 2 TO 4 LESIONS" 11056_3 CDM 360 RC 11056 HCPCS outpatient 172 129 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 151.36 88 999999999 134.16 163.4 percent of total billed charges "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); 2 TO 4 LESIONS" 11056_3 CDM 360 RC 11056 HCPCS outpatient 172 129 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 153.08 89 999999999 134.16 163.4 percent of total billed charges "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); MORE THAN 4 LESIONS" 11057_3 CDM 360 RC 11057 HCPCS outpatient 189 141.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 170.1 999999999 147.42 179.55 case rate "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); MORE THAN 4 LESIONS" 11057_3 CDM 360 RC 11057 HCPCS outpatient 189 141.75 AETNA MCR ADV AETNA MCR ADV 147.42 78 999999999 147.42 179.55 percent of total billed charges "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); MORE THAN 4 LESIONS" 11057_3 CDM 360 RC 11057 HCPCS outpatient 189 141.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 165.51 87.57 999999999 147.42 179.55 percent of total billed charges "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); MORE THAN 4 LESIONS" 11057_3 CDM 360 RC 11057 HCPCS outpatient 189 141.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 160.78 85.07 999999999 147.42 179.55 percent of total billed charges "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); MORE THAN 4 LESIONS" 11057_3 CDM 360 RC 11057 HCPCS outpatient 189 141.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 160.78 85.07 999999999 147.42 179.55 percent of total billed charges "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); MORE THAN 4 LESIONS" 11057_3 CDM 360 RC 11057 HCPCS outpatient 189 141.75 MOLINA MCAID MOLINA MCAID 157.63 83.4 999999999 147.42 179.55 percent of total billed charges "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); MORE THAN 4 LESIONS" 11057_3 CDM 360 RC 11057 HCPCS outpatient 189 141.75 MOLINA MCR ADV MOLINA MCR ADV 168.21 89 999999999 147.42 179.55 percent of total billed charges "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); MORE THAN 4 LESIONS" 11057_3 CDM 360 RC 11057 HCPCS outpatient 189 141.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 168.21 89 999999999 147.42 179.55 percent of total billed charges "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); MORE THAN 4 LESIONS" 11057_3 CDM 360 RC 11057 HCPCS outpatient 189 141.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 168.21 89 999999999 147.42 179.55 percent of total billed charges "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); MORE THAN 4 LESIONS" 11057_3 CDM 360 RC 11057 HCPCS outpatient 189 141.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 170.1 90 999999999 147.42 179.55 percent of total billed charges "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); MORE THAN 4 LESIONS" 11057_3 CDM 360 RC 11057 HCPCS outpatient 189 141.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 179.55 95 999999999 147.42 179.55 percent of total billed charges "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); MORE THAN 4 LESIONS" 11057_3 CDM 360 RC 11057 HCPCS outpatient 189 141.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 179.55 95 999999999 147.42 179.55 percent of total billed charges "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); MORE THAN 4 LESIONS" 11057_3 CDM 360 RC 11057 HCPCS outpatient 189 141.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 168.21 89 999999999 147.42 179.55 percent of total billed charges "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); MORE THAN 4 LESIONS" 11057_3 CDM 360 RC 11057 HCPCS outpatient 189 141.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 166.32 88 999999999 147.42 179.55 percent of total billed charges "PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); MORE THAN 4 LESIONS" 11057_3 CDM 360 RC 11057 HCPCS outpatient 189 141.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 168.21 89 999999999 147.42 179.55 percent of total billed charges "TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); SINGLE LESION" 11102_3 CDM 361 RC 11102 HCPCS outpatient 213 159.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 191.7 999999999 166.14 202.35 case rate "TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); SINGLE LESION" 11102_3 CDM 361 RC 11102 HCPCS outpatient 213 159.75 AETNA MCR ADV AETNA MCR ADV 166.14 78 999999999 166.14 202.35 percent of total billed charges "TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); SINGLE LESION" 11102_3 CDM 361 RC 11102 HCPCS outpatient 213 159.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 186.52 87.57 999999999 166.14 202.35 percent of total billed charges "TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); SINGLE LESION" 11102_3 CDM 361 RC 11102 HCPCS outpatient 213 159.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 181.2 85.07 999999999 166.14 202.35 percent of total billed charges "TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); SINGLE LESION" 11102_3 CDM 361 RC 11102 HCPCS outpatient 213 159.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 181.2 85.07 999999999 166.14 202.35 percent of total billed charges "TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); SINGLE LESION" 11102_3 CDM 361 RC 11102 HCPCS outpatient 213 159.75 MOLINA MCAID MOLINA MCAID 177.64 83.4 999999999 166.14 202.35 percent of total billed charges "TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); SINGLE LESION" 11102_3 CDM 361 RC 11102 HCPCS outpatient 213 159.75 MOLINA MCR ADV MOLINA MCR ADV 189.57 89 999999999 166.14 202.35 percent of total billed charges "TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); SINGLE LESION" 11102_3 CDM 361 RC 11102 HCPCS outpatient 213 159.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 189.57 89 999999999 166.14 202.35 percent of total billed charges "TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); SINGLE LESION" 11102_3 CDM 361 RC 11102 HCPCS outpatient 213 159.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 189.57 89 999999999 166.14 202.35 percent of total billed charges "TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); SINGLE LESION" 11102_3 CDM 361 RC 11102 HCPCS outpatient 213 159.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 191.7 90 999999999 166.14 202.35 percent of total billed charges "TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); SINGLE LESION" 11102_3 CDM 361 RC 11102 HCPCS outpatient 213 159.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 202.35 95 999999999 166.14 202.35 percent of total billed charges "TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); SINGLE LESION" 11102_3 CDM 361 RC 11102 HCPCS outpatient 213 159.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 202.35 95 999999999 166.14 202.35 percent of total billed charges "TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); SINGLE LESION" 11102_3 CDM 361 RC 11102 HCPCS outpatient 213 159.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 189.57 89 999999999 166.14 202.35 percent of total billed charges "TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); SINGLE LESION" 11102_3 CDM 361 RC 11102 HCPCS outpatient 213 159.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 187.44 88 999999999 166.14 202.35 percent of total billed charges "TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); SINGLE LESION" 11102_3 CDM 361 RC 11102 HCPCS outpatient 213 159.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 189.57 89 999999999 166.14 202.35 percent of total billed charges "TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); EACH SEPARATE/ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11103_3 CDM 361 RC 11103 HCPCS outpatient 106 79.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 95.4 999999999 82.68 100.7 case rate "TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); EACH SEPARATE/ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11103_3 CDM 361 RC 11103 HCPCS outpatient 106 79.5 AETNA MCR ADV AETNA MCR ADV 82.68 78 999999999 82.68 100.7 percent of total billed charges "TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); EACH SEPARATE/ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11103_3 CDM 361 RC 11103 HCPCS outpatient 106 79.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 92.82 87.57 999999999 82.68 100.7 percent of total billed charges "TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); EACH SEPARATE/ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11103_3 CDM 361 RC 11103 HCPCS outpatient 106 79.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 90.17 85.07 999999999 82.68 100.7 percent of total billed charges "TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); EACH SEPARATE/ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11103_3 CDM 361 RC 11103 HCPCS outpatient 106 79.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 90.17 85.07 999999999 82.68 100.7 percent of total billed charges "TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); EACH SEPARATE/ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11103_3 CDM 361 RC 11103 HCPCS outpatient 106 79.5 MOLINA MCAID MOLINA MCAID 88.4 83.4 999999999 82.68 100.7 percent of total billed charges "TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); EACH SEPARATE/ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11103_3 CDM 361 RC 11103 HCPCS outpatient 106 79.5 MOLINA MCR ADV MOLINA MCR ADV 94.34 89 999999999 82.68 100.7 percent of total billed charges "TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); EACH SEPARATE/ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11103_3 CDM 361 RC 11103 HCPCS outpatient 106 79.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 94.34 89 999999999 82.68 100.7 percent of total billed charges "TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); EACH SEPARATE/ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11103_3 CDM 361 RC 11103 HCPCS outpatient 106 79.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 94.34 89 999999999 82.68 100.7 percent of total billed charges "TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); EACH SEPARATE/ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11103_3 CDM 361 RC 11103 HCPCS outpatient 106 79.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 95.4 90 999999999 82.68 100.7 percent of total billed charges "TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); EACH SEPARATE/ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11103_3 CDM 361 RC 11103 HCPCS outpatient 106 79.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 100.7 95 999999999 82.68 100.7 percent of total billed charges "TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); EACH SEPARATE/ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11103_3 CDM 361 RC 11103 HCPCS outpatient 106 79.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 100.7 95 999999999 82.68 100.7 percent of total billed charges "TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); EACH SEPARATE/ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11103_3 CDM 361 RC 11103 HCPCS outpatient 106 79.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 94.34 89 999999999 82.68 100.7 percent of total billed charges "TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); EACH SEPARATE/ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11103_3 CDM 361 RC 11103 HCPCS outpatient 106 79.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 93.28 88 999999999 82.68 100.7 percent of total billed charges "TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); EACH SEPARATE/ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11103_3 CDM 361 RC 11103 HCPCS outpatient 106 79.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 94.34 89 999999999 82.68 100.7 percent of total billed charges "PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION" 11104_3 CDM 361 RC 11104 HCPCS outpatient 264 198 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 237.6 999999999 205.92 250.8 case rate "PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION" 11104_3 CDM 361 RC 11104 HCPCS outpatient 264 198 AETNA MCR ADV AETNA MCR ADV 205.92 78 999999999 205.92 250.8 percent of total billed charges "PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION" 11104_3 CDM 361 RC 11104 HCPCS outpatient 264 198 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 231.18 87.57 999999999 205.92 250.8 percent of total billed charges "PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION" 11104_3 CDM 361 RC 11104 HCPCS outpatient 264 198 COORDINATED CARE MCAID COORDINATED CARE MCAID 224.58 85.07 999999999 205.92 250.8 percent of total billed charges "PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION" 11104_3 CDM 361 RC 11104 HCPCS outpatient 264 198 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 224.58 85.07 999999999 205.92 250.8 percent of total billed charges "PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION" 11104_3 CDM 361 RC 11104 HCPCS outpatient 264 198 MOLINA MCAID MOLINA MCAID 220.18 83.4 999999999 205.92 250.8 percent of total billed charges "PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION" 11104_3 CDM 361 RC 11104 HCPCS outpatient 264 198 MOLINA MCR ADV MOLINA MCR ADV 234.96 89 999999999 205.92 250.8 percent of total billed charges "PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION" 11104_3 CDM 361 RC 11104 HCPCS outpatient 264 198 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 234.96 89 999999999 205.92 250.8 percent of total billed charges "PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION" 11104_3 CDM 361 RC 11104 HCPCS outpatient 264 198 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 234.96 89 999999999 205.92 250.8 percent of total billed charges "PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION" 11104_3 CDM 361 RC 11104 HCPCS outpatient 264 198 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 237.6 90 999999999 205.92 250.8 percent of total billed charges "PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION" 11104_3 CDM 361 RC 11104 HCPCS outpatient 264 198 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 250.8 95 999999999 205.92 250.8 percent of total billed charges "PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION" 11104_3 CDM 361 RC 11104 HCPCS outpatient 264 198 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 250.8 95 999999999 205.92 250.8 percent of total billed charges "PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION" 11104_3 CDM 361 RC 11104 HCPCS outpatient 264 198 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 234.96 89 999999999 205.92 250.8 percent of total billed charges "PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION" 11104_3 CDM 361 RC 11104 HCPCS outpatient 264 198 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 232.32 88 999999999 205.92 250.8 percent of total billed charges "PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION" 11104_3 CDM 361 RC 11104 HCPCS outpatient 264 198 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 234.96 89 999999999 205.92 250.8 percent of total billed charges "INCISIONAL BIOPSY OF SKIN (EG, WEDGE) (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION" 11106_3 CDM 361 RC 11106 HCPCS outpatient 326 244.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 293.4 999999999 254.28 309.7 case rate "INCISIONAL BIOPSY OF SKIN (EG, WEDGE) (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION" 11106_3 CDM 361 RC 11106 HCPCS outpatient 326 244.5 AETNA MCR ADV AETNA MCR ADV 254.28 78 999999999 254.28 309.7 percent of total billed charges "INCISIONAL BIOPSY OF SKIN (EG, WEDGE) (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION" 11106_3 CDM 361 RC 11106 HCPCS outpatient 326 244.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 285.48 87.57 999999999 254.28 309.7 percent of total billed charges "INCISIONAL BIOPSY OF SKIN (EG, WEDGE) (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION" 11106_3 CDM 361 RC 11106 HCPCS outpatient 326 244.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 277.33 85.07 999999999 254.28 309.7 percent of total billed charges "INCISIONAL BIOPSY OF SKIN (EG, WEDGE) (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION" 11106_3 CDM 361 RC 11106 HCPCS outpatient 326 244.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 277.33 85.07 999999999 254.28 309.7 percent of total billed charges "INCISIONAL BIOPSY OF SKIN (EG, WEDGE) (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION" 11106_3 CDM 361 RC 11106 HCPCS outpatient 326 244.5 MOLINA MCAID MOLINA MCAID 271.88 83.4 999999999 254.28 309.7 percent of total billed charges "INCISIONAL BIOPSY OF SKIN (EG, WEDGE) (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION" 11106_3 CDM 361 RC 11106 HCPCS outpatient 326 244.5 MOLINA MCR ADV MOLINA MCR ADV 290.14 89 999999999 254.28 309.7 percent of total billed charges "INCISIONAL BIOPSY OF SKIN (EG, WEDGE) (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION" 11106_3 CDM 361 RC 11106 HCPCS outpatient 326 244.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 290.14 89 999999999 254.28 309.7 percent of total billed charges "INCISIONAL BIOPSY OF SKIN (EG, WEDGE) (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION" 11106_3 CDM 361 RC 11106 HCPCS outpatient 326 244.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 290.14 89 999999999 254.28 309.7 percent of total billed charges "INCISIONAL BIOPSY OF SKIN (EG, WEDGE) (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION" 11106_3 CDM 361 RC 11106 HCPCS outpatient 326 244.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 293.4 90 999999999 254.28 309.7 percent of total billed charges "INCISIONAL BIOPSY OF SKIN (EG, WEDGE) (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION" 11106_3 CDM 361 RC 11106 HCPCS outpatient 326 244.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 309.7 95 999999999 254.28 309.7 percent of total billed charges "INCISIONAL BIOPSY OF SKIN (EG, WEDGE) (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION" 11106_3 CDM 361 RC 11106 HCPCS outpatient 326 244.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 309.7 95 999999999 254.28 309.7 percent of total billed charges "INCISIONAL BIOPSY OF SKIN (EG, WEDGE) (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION" 11106_3 CDM 361 RC 11106 HCPCS outpatient 326 244.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 290.14 89 999999999 254.28 309.7 percent of total billed charges "INCISIONAL BIOPSY OF SKIN (EG, WEDGE) (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION" 11106_3 CDM 361 RC 11106 HCPCS outpatient 326 244.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 286.88 88 999999999 254.28 309.7 percent of total billed charges "INCISIONAL BIOPSY OF SKIN (EG, WEDGE) (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION" 11106_3 CDM 361 RC 11106 HCPCS outpatient 326 244.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 290.14 89 999999999 254.28 309.7 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_1 CDM 360 RC 11200 HCPCS outpatient 229.98 172.49 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 206.98 999999999 179.38 218.48 case rate "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_1 CDM 360 RC 11200 HCPCS outpatient 229.98 172.49 AETNA MCR ADV AETNA MCR ADV 179.38 78 999999999 179.38 218.48 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_1 CDM 360 RC 11200 HCPCS outpatient 229.98 172.49 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 201.39 87.57 999999999 179.38 218.48 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_1 CDM 360 RC 11200 HCPCS outpatient 229.98 172.49 COORDINATED CARE MCAID COORDINATED CARE MCAID 195.64 85.07 999999999 179.38 218.48 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_1 CDM 360 RC 11200 HCPCS outpatient 229.98 172.49 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 195.64 85.07 999999999 179.38 218.48 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_1 CDM 360 RC 11200 HCPCS outpatient 229.98 172.49 MOLINA MCAID MOLINA MCAID 191.8 83.4 999999999 179.38 218.48 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_1 CDM 360 RC 11200 HCPCS outpatient 229.98 172.49 MOLINA MCR ADV MOLINA MCR ADV 204.68 89 999999999 179.38 218.48 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_1 CDM 360 RC 11200 HCPCS outpatient 229.98 172.49 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 204.68 89 999999999 179.38 218.48 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_1 CDM 360 RC 11200 HCPCS outpatient 229.98 172.49 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 204.68 89 999999999 179.38 218.48 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_1 CDM 360 RC 11200 HCPCS outpatient 229.98 172.49 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 206.98 90 999999999 179.38 218.48 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_1 CDM 360 RC 11200 HCPCS outpatient 229.98 172.49 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 218.48 95 999999999 179.38 218.48 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_1 CDM 360 RC 11200 HCPCS outpatient 229.98 172.49 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 218.48 95 999999999 179.38 218.48 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_1 CDM 360 RC 11200 HCPCS outpatient 229.98 172.49 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 204.68 89 999999999 179.38 218.48 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_1 CDM 360 RC 11200 HCPCS outpatient 229.98 172.49 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 202.38 88 999999999 179.38 218.48 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_1 CDM 360 RC 11200 HCPCS outpatient 229.98 172.49 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 204.68 89 999999999 179.38 218.48 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_2 CDM 360 RC 11200 HCPCS outpatient 229.98 172.49 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 206.98 999999999 179.38 218.48 case rate "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_2 CDM 360 RC 11200 HCPCS outpatient 229.98 172.49 AETNA MCR ADV AETNA MCR ADV 179.38 78 999999999 179.38 218.48 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_2 CDM 360 RC 11200 HCPCS outpatient 229.98 172.49 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 201.39 87.57 999999999 179.38 218.48 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_2 CDM 360 RC 11200 HCPCS outpatient 229.98 172.49 COORDINATED CARE MCAID COORDINATED CARE MCAID 195.64 85.07 999999999 179.38 218.48 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_2 CDM 360 RC 11200 HCPCS outpatient 229.98 172.49 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 195.64 85.07 999999999 179.38 218.48 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_2 CDM 360 RC 11200 HCPCS outpatient 229.98 172.49 MOLINA MCAID MOLINA MCAID 191.8 83.4 999999999 179.38 218.48 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_2 CDM 360 RC 11200 HCPCS outpatient 229.98 172.49 MOLINA MCR ADV MOLINA MCR ADV 204.68 89 999999999 179.38 218.48 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_2 CDM 360 RC 11200 HCPCS outpatient 229.98 172.49 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 204.68 89 999999999 179.38 218.48 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_2 CDM 360 RC 11200 HCPCS outpatient 229.98 172.49 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 204.68 89 999999999 179.38 218.48 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_2 CDM 360 RC 11200 HCPCS outpatient 229.98 172.49 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 206.98 90 999999999 179.38 218.48 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_2 CDM 360 RC 11200 HCPCS outpatient 229.98 172.49 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 218.48 95 999999999 179.38 218.48 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_2 CDM 360 RC 11200 HCPCS outpatient 229.98 172.49 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 218.48 95 999999999 179.38 218.48 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_2 CDM 360 RC 11200 HCPCS outpatient 229.98 172.49 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 204.68 89 999999999 179.38 218.48 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_2 CDM 360 RC 11200 HCPCS outpatient 229.98 172.49 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 202.38 88 999999999 179.38 218.48 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_2 CDM 360 RC 11200 HCPCS outpatient 229.98 172.49 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 204.68 89 999999999 179.38 218.48 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_3 CDM 360 RC 11200 HCPCS outpatient 185 138.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 166.5 999999999 144.3 175.75 case rate "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_3 CDM 360 RC 11200 HCPCS outpatient 185 138.75 AETNA MCR ADV AETNA MCR ADV 144.3 78 999999999 144.3 175.75 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_3 CDM 360 RC 11200 HCPCS outpatient 185 138.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 162 87.57 999999999 144.3 175.75 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_3 CDM 360 RC 11200 HCPCS outpatient 185 138.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 157.38 85.07 999999999 144.3 175.75 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_3 CDM 360 RC 11200 HCPCS outpatient 185 138.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 157.38 85.07 999999999 144.3 175.75 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_3 CDM 360 RC 11200 HCPCS outpatient 185 138.75 MOLINA MCAID MOLINA MCAID 154.29 83.4 999999999 144.3 175.75 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_3 CDM 360 RC 11200 HCPCS outpatient 185 138.75 MOLINA MCR ADV MOLINA MCR ADV 164.65 89 999999999 144.3 175.75 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_3 CDM 360 RC 11200 HCPCS outpatient 185 138.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 164.65 89 999999999 144.3 175.75 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_3 CDM 360 RC 11200 HCPCS outpatient 185 138.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 164.65 89 999999999 144.3 175.75 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_3 CDM 360 RC 11200 HCPCS outpatient 185 138.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 166.5 90 999999999 144.3 175.75 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_3 CDM 360 RC 11200 HCPCS outpatient 185 138.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 175.75 95 999999999 144.3 175.75 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_3 CDM 360 RC 11200 HCPCS outpatient 185 138.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 175.75 95 999999999 144.3 175.75 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_3 CDM 360 RC 11200 HCPCS outpatient 185 138.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 164.65 89 999999999 144.3 175.75 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_3 CDM 360 RC 11200 HCPCS outpatient 185 138.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 162.8 88 999999999 144.3 175.75 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 11200_3 CDM 360 RC 11200 HCPCS outpatient 185 138.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 164.65 89 999999999 144.3 175.75 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; EACH ADDITIONAL 10 LESIONS, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11201_3 CDM 360 RC 11201 HCPCS outpatient 37 27.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 33.3 999999999 28.86 35.15 case rate "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; EACH ADDITIONAL 10 LESIONS, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11201_3 CDM 360 RC 11201 HCPCS outpatient 37 27.75 AETNA MCR ADV AETNA MCR ADV 28.86 78 999999999 28.86 35.15 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; EACH ADDITIONAL 10 LESIONS, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11201_3 CDM 360 RC 11201 HCPCS outpatient 37 27.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 32.4 87.57 999999999 28.86 35.15 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; EACH ADDITIONAL 10 LESIONS, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11201_3 CDM 360 RC 11201 HCPCS outpatient 37 27.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 31.48 85.07 999999999 28.86 35.15 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; EACH ADDITIONAL 10 LESIONS, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11201_3 CDM 360 RC 11201 HCPCS outpatient 37 27.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 31.48 85.07 999999999 28.86 35.15 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; EACH ADDITIONAL 10 LESIONS, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11201_3 CDM 360 RC 11201 HCPCS outpatient 37 27.75 MOLINA MCAID MOLINA MCAID 30.86 83.4 999999999 28.86 35.15 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; EACH ADDITIONAL 10 LESIONS, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11201_3 CDM 360 RC 11201 HCPCS outpatient 37 27.75 MOLINA MCR ADV MOLINA MCR ADV 32.93 89 999999999 28.86 35.15 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; EACH ADDITIONAL 10 LESIONS, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11201_3 CDM 360 RC 11201 HCPCS outpatient 37 27.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 32.93 89 999999999 28.86 35.15 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; EACH ADDITIONAL 10 LESIONS, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11201_3 CDM 360 RC 11201 HCPCS outpatient 37 27.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 32.93 89 999999999 28.86 35.15 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; EACH ADDITIONAL 10 LESIONS, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11201_3 CDM 360 RC 11201 HCPCS outpatient 37 27.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 33.3 90 999999999 28.86 35.15 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; EACH ADDITIONAL 10 LESIONS, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11201_3 CDM 360 RC 11201 HCPCS outpatient 37 27.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 35.15 95 999999999 28.86 35.15 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; EACH ADDITIONAL 10 LESIONS, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11201_3 CDM 360 RC 11201 HCPCS outpatient 37 27.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 35.15 95 999999999 28.86 35.15 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; EACH ADDITIONAL 10 LESIONS, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11201_3 CDM 360 RC 11201 HCPCS outpatient 37 27.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 32.93 89 999999999 28.86 35.15 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; EACH ADDITIONAL 10 LESIONS, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11201_3 CDM 360 RC 11201 HCPCS outpatient 37 27.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 32.56 88 999999999 28.86 35.15 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; EACH ADDITIONAL 10 LESIONS, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11201_3 CDM 360 RC 11201 HCPCS outpatient 37 27.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 32.93 89 999999999 28.86 35.15 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.5 CM OR LESS" 11300_3 CDM 360 RC 11300 HCPCS outpatient 213 159.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 191.7 999999999 166.14 202.35 case rate "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.5 CM OR LESS" 11300_3 CDM 360 RC 11300 HCPCS outpatient 213 159.75 AETNA MCR ADV AETNA MCR ADV 166.14 78 999999999 166.14 202.35 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.5 CM OR LESS" 11300_3 CDM 360 RC 11300 HCPCS outpatient 213 159.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 186.52 87.57 999999999 166.14 202.35 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.5 CM OR LESS" 11300_3 CDM 360 RC 11300 HCPCS outpatient 213 159.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 181.2 85.07 999999999 166.14 202.35 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.5 CM OR LESS" 11300_3 CDM 360 RC 11300 HCPCS outpatient 213 159.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 181.2 85.07 999999999 166.14 202.35 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.5 CM OR LESS" 11300_3 CDM 360 RC 11300 HCPCS outpatient 213 159.75 MOLINA MCAID MOLINA MCAID 177.64 83.4 999999999 166.14 202.35 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.5 CM OR LESS" 11300_3 CDM 360 RC 11300 HCPCS outpatient 213 159.75 MOLINA MCR ADV MOLINA MCR ADV 189.57 89 999999999 166.14 202.35 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.5 CM OR LESS" 11300_3 CDM 360 RC 11300 HCPCS outpatient 213 159.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 189.57 89 999999999 166.14 202.35 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.5 CM OR LESS" 11300_3 CDM 360 RC 11300 HCPCS outpatient 213 159.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 189.57 89 999999999 166.14 202.35 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.5 CM OR LESS" 11300_3 CDM 360 RC 11300 HCPCS outpatient 213 159.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 191.7 90 999999999 166.14 202.35 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.5 CM OR LESS" 11300_3 CDM 360 RC 11300 HCPCS outpatient 213 159.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 202.35 95 999999999 166.14 202.35 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.5 CM OR LESS" 11300_3 CDM 360 RC 11300 HCPCS outpatient 213 159.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 202.35 95 999999999 166.14 202.35 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.5 CM OR LESS" 11300_3 CDM 360 RC 11300 HCPCS outpatient 213 159.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 189.57 89 999999999 166.14 202.35 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.5 CM OR LESS" 11300_3 CDM 360 RC 11300 HCPCS outpatient 213 159.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 187.44 88 999999999 166.14 202.35 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.5 CM OR LESS" 11300_3 CDM 360 RC 11300 HCPCS outpatient 213 159.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 189.57 89 999999999 166.14 202.35 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.6 TO 1.0 CM" 11301_3 CDM 360 RC 11301 HCPCS outpatient 254 190.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 228.6 999999999 198.12 241.3 case rate "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.6 TO 1.0 CM" 11301_3 CDM 360 RC 11301 HCPCS outpatient 254 190.5 AETNA MCR ADV AETNA MCR ADV 198.12 78 999999999 198.12 241.3 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.6 TO 1.0 CM" 11301_3 CDM 360 RC 11301 HCPCS outpatient 254 190.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 222.43 87.57 999999999 198.12 241.3 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.6 TO 1.0 CM" 11301_3 CDM 360 RC 11301 HCPCS outpatient 254 190.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 216.08 85.07 999999999 198.12 241.3 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.6 TO 1.0 CM" 11301_3 CDM 360 RC 11301 HCPCS outpatient 254 190.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 216.08 85.07 999999999 198.12 241.3 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.6 TO 1.0 CM" 11301_3 CDM 360 RC 11301 HCPCS outpatient 254 190.5 MOLINA MCAID MOLINA MCAID 211.84 83.4 999999999 198.12 241.3 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.6 TO 1.0 CM" 11301_3 CDM 360 RC 11301 HCPCS outpatient 254 190.5 MOLINA MCR ADV MOLINA MCR ADV 226.06 89 999999999 198.12 241.3 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.6 TO 1.0 CM" 11301_3 CDM 360 RC 11301 HCPCS outpatient 254 190.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 226.06 89 999999999 198.12 241.3 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.6 TO 1.0 CM" 11301_3 CDM 360 RC 11301 HCPCS outpatient 254 190.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 226.06 89 999999999 198.12 241.3 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.6 TO 1.0 CM" 11301_3 CDM 360 RC 11301 HCPCS outpatient 254 190.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 228.6 90 999999999 198.12 241.3 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.6 TO 1.0 CM" 11301_3 CDM 360 RC 11301 HCPCS outpatient 254 190.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 241.3 95 999999999 198.12 241.3 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.6 TO 1.0 CM" 11301_3 CDM 360 RC 11301 HCPCS outpatient 254 190.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 241.3 95 999999999 198.12 241.3 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.6 TO 1.0 CM" 11301_3 CDM 360 RC 11301 HCPCS outpatient 254 190.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 226.06 89 999999999 198.12 241.3 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.6 TO 1.0 CM" 11301_3 CDM 360 RC 11301 HCPCS outpatient 254 190.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 223.52 88 999999999 198.12 241.3 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.6 TO 1.0 CM" 11301_3 CDM 360 RC 11301 HCPCS outpatient 254 190.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 226.06 89 999999999 198.12 241.3 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 1.1 TO 2.0 CM" 11302_3 CDM 360 RC 11302 HCPCS outpatient 288 216 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 259.2 999999999 224.64 273.6 case rate "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 1.1 TO 2.0 CM" 11302_3 CDM 360 RC 11302 HCPCS outpatient 288 216 AETNA MCR ADV AETNA MCR ADV 224.64 78 999999999 224.64 273.6 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 1.1 TO 2.0 CM" 11302_3 CDM 360 RC 11302 HCPCS outpatient 288 216 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 252.2 87.57 999999999 224.64 273.6 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 1.1 TO 2.0 CM" 11302_3 CDM 360 RC 11302 HCPCS outpatient 288 216 COORDINATED CARE MCAID COORDINATED CARE MCAID 245 85.07 999999999 224.64 273.6 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 1.1 TO 2.0 CM" 11302_3 CDM 360 RC 11302 HCPCS outpatient 288 216 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 245 85.07 999999999 224.64 273.6 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 1.1 TO 2.0 CM" 11302_3 CDM 360 RC 11302 HCPCS outpatient 288 216 MOLINA MCAID MOLINA MCAID 240.19 83.4 999999999 224.64 273.6 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 1.1 TO 2.0 CM" 11302_3 CDM 360 RC 11302 HCPCS outpatient 288 216 MOLINA MCR ADV MOLINA MCR ADV 256.32 89 999999999 224.64 273.6 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 1.1 TO 2.0 CM" 11302_3 CDM 360 RC 11302 HCPCS outpatient 288 216 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 256.32 89 999999999 224.64 273.6 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 1.1 TO 2.0 CM" 11302_3 CDM 360 RC 11302 HCPCS outpatient 288 216 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 256.32 89 999999999 224.64 273.6 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 1.1 TO 2.0 CM" 11302_3 CDM 360 RC 11302 HCPCS outpatient 288 216 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 259.2 90 999999999 224.64 273.6 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 1.1 TO 2.0 CM" 11302_3 CDM 360 RC 11302 HCPCS outpatient 288 216 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 273.6 95 999999999 224.64 273.6 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 1.1 TO 2.0 CM" 11302_3 CDM 360 RC 11302 HCPCS outpatient 288 216 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 273.6 95 999999999 224.64 273.6 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 1.1 TO 2.0 CM" 11302_3 CDM 360 RC 11302 HCPCS outpatient 288 216 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 256.32 89 999999999 224.64 273.6 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 1.1 TO 2.0 CM" 11302_3 CDM 360 RC 11302 HCPCS outpatient 288 216 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 253.44 88 999999999 224.64 273.6 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 1.1 TO 2.0 CM" 11302_3 CDM 360 RC 11302 HCPCS outpatient 288 216 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 256.32 89 999999999 224.64 273.6 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER OVER 2.0 CM" 11303_3 CDM 360 RC 11303 HCPCS outpatient 317 237.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 285.3 999999999 247.26 301.15 case rate "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER OVER 2.0 CM" 11303_3 CDM 360 RC 11303 HCPCS outpatient 317 237.75 AETNA MCR ADV AETNA MCR ADV 247.26 78 999999999 247.26 301.15 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER OVER 2.0 CM" 11303_3 CDM 360 RC 11303 HCPCS outpatient 317 237.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 277.6 87.57 999999999 247.26 301.15 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER OVER 2.0 CM" 11303_3 CDM 360 RC 11303 HCPCS outpatient 317 237.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 269.67 85.07 999999999 247.26 301.15 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER OVER 2.0 CM" 11303_3 CDM 360 RC 11303 HCPCS outpatient 317 237.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 269.67 85.07 999999999 247.26 301.15 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER OVER 2.0 CM" 11303_3 CDM 360 RC 11303 HCPCS outpatient 317 237.75 MOLINA MCAID MOLINA MCAID 264.38 83.4 999999999 247.26 301.15 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER OVER 2.0 CM" 11303_3 CDM 360 RC 11303 HCPCS outpatient 317 237.75 MOLINA MCR ADV MOLINA MCR ADV 282.13 89 999999999 247.26 301.15 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER OVER 2.0 CM" 11303_3 CDM 360 RC 11303 HCPCS outpatient 317 237.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 282.13 89 999999999 247.26 301.15 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER OVER 2.0 CM" 11303_3 CDM 360 RC 11303 HCPCS outpatient 317 237.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 282.13 89 999999999 247.26 301.15 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER OVER 2.0 CM" 11303_3 CDM 360 RC 11303 HCPCS outpatient 317 237.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 285.3 90 999999999 247.26 301.15 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER OVER 2.0 CM" 11303_3 CDM 360 RC 11303 HCPCS outpatient 317 237.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 301.15 95 999999999 247.26 301.15 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER OVER 2.0 CM" 11303_3 CDM 360 RC 11303 HCPCS outpatient 317 237.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 301.15 95 999999999 247.26 301.15 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER OVER 2.0 CM" 11303_3 CDM 360 RC 11303 HCPCS outpatient 317 237.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 282.13 89 999999999 247.26 301.15 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER OVER 2.0 CM" 11303_3 CDM 360 RC 11303 HCPCS outpatient 317 237.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 278.96 88 999999999 247.26 301.15 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER OVER 2.0 CM" 11303_3 CDM 360 RC 11303 HCPCS outpatient 317 237.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 282.13 89 999999999 247.26 301.15 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.5 CM OR LESS" 11305_3 CDM 360 RC 11305 HCPCS outpatient 224 168 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 201.6 999999999 174.72 212.8 case rate "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.5 CM OR LESS" 11305_3 CDM 360 RC 11305 HCPCS outpatient 224 168 AETNA MCR ADV AETNA MCR ADV 174.72 78 999999999 174.72 212.8 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.5 CM OR LESS" 11305_3 CDM 360 RC 11305 HCPCS outpatient 224 168 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 196.16 87.57 999999999 174.72 212.8 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.5 CM OR LESS" 11305_3 CDM 360 RC 11305 HCPCS outpatient 224 168 COORDINATED CARE MCAID COORDINATED CARE MCAID 190.56 85.07 999999999 174.72 212.8 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.5 CM OR LESS" 11305_3 CDM 360 RC 11305 HCPCS outpatient 224 168 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 190.56 85.07 999999999 174.72 212.8 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.5 CM OR LESS" 11305_3 CDM 360 RC 11305 HCPCS outpatient 224 168 MOLINA MCAID MOLINA MCAID 186.82 83.4 999999999 174.72 212.8 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.5 CM OR LESS" 11305_3 CDM 360 RC 11305 HCPCS outpatient 224 168 MOLINA MCR ADV MOLINA MCR ADV 199.36 89 999999999 174.72 212.8 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.5 CM OR LESS" 11305_3 CDM 360 RC 11305 HCPCS outpatient 224 168 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 199.36 89 999999999 174.72 212.8 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.5 CM OR LESS" 11305_3 CDM 360 RC 11305 HCPCS outpatient 224 168 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 199.36 89 999999999 174.72 212.8 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.5 CM OR LESS" 11305_3 CDM 360 RC 11305 HCPCS outpatient 224 168 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 201.6 90 999999999 174.72 212.8 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.5 CM OR LESS" 11305_3 CDM 360 RC 11305 HCPCS outpatient 224 168 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 212.8 95 999999999 174.72 212.8 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.5 CM OR LESS" 11305_3 CDM 360 RC 11305 HCPCS outpatient 224 168 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 212.8 95 999999999 174.72 212.8 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.5 CM OR LESS" 11305_3 CDM 360 RC 11305 HCPCS outpatient 224 168 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 199.36 89 999999999 174.72 212.8 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.5 CM OR LESS" 11305_3 CDM 360 RC 11305 HCPCS outpatient 224 168 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 197.12 88 999999999 174.72 212.8 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.5 CM OR LESS" 11305_3 CDM 360 RC 11305 HCPCS outpatient 224 168 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 199.36 89 999999999 174.72 212.8 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.6 TO 1.0 CM" 11306_3 CDM 360 RC 11306 HCPCS outpatient 256 192 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 230.4 999999999 199.68 243.2 case rate "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.6 TO 1.0 CM" 11306_3 CDM 360 RC 11306 HCPCS outpatient 256 192 AETNA MCR ADV AETNA MCR ADV 199.68 78 999999999 199.68 243.2 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.6 TO 1.0 CM" 11306_3 CDM 360 RC 11306 HCPCS outpatient 256 192 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 224.18 87.57 999999999 199.68 243.2 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.6 TO 1.0 CM" 11306_3 CDM 360 RC 11306 HCPCS outpatient 256 192 COORDINATED CARE MCAID COORDINATED CARE MCAID 217.78 85.07 999999999 199.68 243.2 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.6 TO 1.0 CM" 11306_3 CDM 360 RC 11306 HCPCS outpatient 256 192 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 217.78 85.07 999999999 199.68 243.2 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.6 TO 1.0 CM" 11306_3 CDM 360 RC 11306 HCPCS outpatient 256 192 MOLINA MCAID MOLINA MCAID 213.5 83.4 999999999 199.68 243.2 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.6 TO 1.0 CM" 11306_3 CDM 360 RC 11306 HCPCS outpatient 256 192 MOLINA MCR ADV MOLINA MCR ADV 227.84 89 999999999 199.68 243.2 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.6 TO 1.0 CM" 11306_3 CDM 360 RC 11306 HCPCS outpatient 256 192 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 227.84 89 999999999 199.68 243.2 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.6 TO 1.0 CM" 11306_3 CDM 360 RC 11306 HCPCS outpatient 256 192 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 227.84 89 999999999 199.68 243.2 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.6 TO 1.0 CM" 11306_3 CDM 360 RC 11306 HCPCS outpatient 256 192 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 230.4 90 999999999 199.68 243.2 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.6 TO 1.0 CM" 11306_3 CDM 360 RC 11306 HCPCS outpatient 256 192 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 243.2 95 999999999 199.68 243.2 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.6 TO 1.0 CM" 11306_3 CDM 360 RC 11306 HCPCS outpatient 256 192 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 243.2 95 999999999 199.68 243.2 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.6 TO 1.0 CM" 11306_3 CDM 360 RC 11306 HCPCS outpatient 256 192 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 227.84 89 999999999 199.68 243.2 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.6 TO 1.0 CM" 11306_3 CDM 360 RC 11306 HCPCS outpatient 256 192 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 225.28 88 999999999 199.68 243.2 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.6 TO 1.0 CM" 11306_3 CDM 360 RC 11306 HCPCS outpatient 256 192 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 227.84 89 999999999 199.68 243.2 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 1.1 TO 2.0 CM" 11307_3 CDM 360 RC 11307 HCPCS outpatient 293 219.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 263.7 999999999 228.54 278.35 case rate "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 1.1 TO 2.0 CM" 11307_3 CDM 360 RC 11307 HCPCS outpatient 293 219.75 AETNA MCR ADV AETNA MCR ADV 228.54 78 999999999 228.54 278.35 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 1.1 TO 2.0 CM" 11307_3 CDM 360 RC 11307 HCPCS outpatient 293 219.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 256.58 87.57 999999999 228.54 278.35 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 1.1 TO 2.0 CM" 11307_3 CDM 360 RC 11307 HCPCS outpatient 293 219.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 249.26 85.07 999999999 228.54 278.35 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 1.1 TO 2.0 CM" 11307_3 CDM 360 RC 11307 HCPCS outpatient 293 219.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 249.26 85.07 999999999 228.54 278.35 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 1.1 TO 2.0 CM" 11307_3 CDM 360 RC 11307 HCPCS outpatient 293 219.75 MOLINA MCAID MOLINA MCAID 244.36 83.4 999999999 228.54 278.35 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 1.1 TO 2.0 CM" 11307_3 CDM 360 RC 11307 HCPCS outpatient 293 219.75 MOLINA MCR ADV MOLINA MCR ADV 260.77 89 999999999 228.54 278.35 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 1.1 TO 2.0 CM" 11307_3 CDM 360 RC 11307 HCPCS outpatient 293 219.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 260.77 89 999999999 228.54 278.35 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 1.1 TO 2.0 CM" 11307_3 CDM 360 RC 11307 HCPCS outpatient 293 219.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 260.77 89 999999999 228.54 278.35 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 1.1 TO 2.0 CM" 11307_3 CDM 360 RC 11307 HCPCS outpatient 293 219.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 263.7 90 999999999 228.54 278.35 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 1.1 TO 2.0 CM" 11307_3 CDM 360 RC 11307 HCPCS outpatient 293 219.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 278.35 95 999999999 228.54 278.35 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 1.1 TO 2.0 CM" 11307_3 CDM 360 RC 11307 HCPCS outpatient 293 219.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 278.35 95 999999999 228.54 278.35 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 1.1 TO 2.0 CM" 11307_3 CDM 360 RC 11307 HCPCS outpatient 293 219.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 260.77 89 999999999 228.54 278.35 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 1.1 TO 2.0 CM" 11307_3 CDM 360 RC 11307 HCPCS outpatient 293 219.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 257.84 88 999999999 228.54 278.35 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 1.1 TO 2.0 CM" 11307_3 CDM 360 RC 11307 HCPCS outpatient 293 219.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 260.77 89 999999999 228.54 278.35 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER OVER 2.0 CM" 11308_3 CDM 360 RC 11308 HCPCS outpatient 310 232.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 279 999999999 241.8 294.5 case rate "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER OVER 2.0 CM" 11308_3 CDM 360 RC 11308 HCPCS outpatient 310 232.5 AETNA MCR ADV AETNA MCR ADV 241.8 78 999999999 241.8 294.5 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER OVER 2.0 CM" 11308_3 CDM 360 RC 11308 HCPCS outpatient 310 232.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 271.47 87.57 999999999 241.8 294.5 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER OVER 2.0 CM" 11308_3 CDM 360 RC 11308 HCPCS outpatient 310 232.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 263.72 85.07 999999999 241.8 294.5 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER OVER 2.0 CM" 11308_3 CDM 360 RC 11308 HCPCS outpatient 310 232.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 263.72 85.07 999999999 241.8 294.5 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER OVER 2.0 CM" 11308_3 CDM 360 RC 11308 HCPCS outpatient 310 232.5 MOLINA MCAID MOLINA MCAID 258.54 83.4 999999999 241.8 294.5 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER OVER 2.0 CM" 11308_3 CDM 360 RC 11308 HCPCS outpatient 310 232.5 MOLINA MCR ADV MOLINA MCR ADV 275.9 89 999999999 241.8 294.5 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER OVER 2.0 CM" 11308_3 CDM 360 RC 11308 HCPCS outpatient 310 232.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 275.9 89 999999999 241.8 294.5 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER OVER 2.0 CM" 11308_3 CDM 360 RC 11308 HCPCS outpatient 310 232.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 275.9 89 999999999 241.8 294.5 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER OVER 2.0 CM" 11308_3 CDM 360 RC 11308 HCPCS outpatient 310 232.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 279 90 999999999 241.8 294.5 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER OVER 2.0 CM" 11308_3 CDM 360 RC 11308 HCPCS outpatient 310 232.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 294.5 95 999999999 241.8 294.5 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER OVER 2.0 CM" 11308_3 CDM 360 RC 11308 HCPCS outpatient 310 232.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 294.5 95 999999999 241.8 294.5 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER OVER 2.0 CM" 11308_3 CDM 360 RC 11308 HCPCS outpatient 310 232.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 275.9 89 999999999 241.8 294.5 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER OVER 2.0 CM" 11308_3 CDM 360 RC 11308 HCPCS outpatient 310 232.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 272.8 88 999999999 241.8 294.5 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER OVER 2.0 CM" 11308_3 CDM 360 RC 11308 HCPCS outpatient 310 232.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 275.9 89 999999999 241.8 294.5 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.6 TO 1.0 CM" 11311_3 CDM 360 RC 11311 HCPCS outpatient 286 214.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 257.4 999999999 223.08 271.7 case rate "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.6 TO 1.0 CM" 11311_3 CDM 360 RC 11311 HCPCS outpatient 286 214.5 AETNA MCR ADV AETNA MCR ADV 223.08 78 999999999 223.08 271.7 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.6 TO 1.0 CM" 11311_3 CDM 360 RC 11311 HCPCS outpatient 286 214.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 250.45 87.57 999999999 223.08 271.7 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.6 TO 1.0 CM" 11311_3 CDM 360 RC 11311 HCPCS outpatient 286 214.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 243.3 85.07 999999999 223.08 271.7 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.6 TO 1.0 CM" 11311_3 CDM 360 RC 11311 HCPCS outpatient 286 214.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 243.3 85.07 999999999 223.08 271.7 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.6 TO 1.0 CM" 11311_3 CDM 360 RC 11311 HCPCS outpatient 286 214.5 MOLINA MCAID MOLINA MCAID 238.52 83.4 999999999 223.08 271.7 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.6 TO 1.0 CM" 11311_3 CDM 360 RC 11311 HCPCS outpatient 286 214.5 MOLINA MCR ADV MOLINA MCR ADV 254.54 89 999999999 223.08 271.7 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.6 TO 1.0 CM" 11311_3 CDM 360 RC 11311 HCPCS outpatient 286 214.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 254.54 89 999999999 223.08 271.7 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.6 TO 1.0 CM" 11311_3 CDM 360 RC 11311 HCPCS outpatient 286 214.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 254.54 89 999999999 223.08 271.7 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.6 TO 1.0 CM" 11311_3 CDM 360 RC 11311 HCPCS outpatient 286 214.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 257.4 90 999999999 223.08 271.7 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.6 TO 1.0 CM" 11311_3 CDM 360 RC 11311 HCPCS outpatient 286 214.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 271.7 95 999999999 223.08 271.7 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.6 TO 1.0 CM" 11311_3 CDM 360 RC 11311 HCPCS outpatient 286 214.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 271.7 95 999999999 223.08 271.7 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.6 TO 1.0 CM" 11311_3 CDM 360 RC 11311 HCPCS outpatient 286 214.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 254.54 89 999999999 223.08 271.7 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.6 TO 1.0 CM" 11311_3 CDM 360 RC 11311 HCPCS outpatient 286 214.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 251.68 88 999999999 223.08 271.7 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.6 TO 1.0 CM" 11311_3 CDM 360 RC 11311 HCPCS outpatient 286 214.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 254.54 89 999999999 223.08 271.7 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 1.1 TO 2.0 CM" 11312_3 CDM 360 RC 11312 HCPCS outpatient 322 241.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 289.8 999999999 251.16 305.9 case rate "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 1.1 TO 2.0 CM" 11312_3 CDM 360 RC 11312 HCPCS outpatient 322 241.5 AETNA MCR ADV AETNA MCR ADV 251.16 78 999999999 251.16 305.9 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 1.1 TO 2.0 CM" 11312_3 CDM 360 RC 11312 HCPCS outpatient 322 241.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 281.98 87.57 999999999 251.16 305.9 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 1.1 TO 2.0 CM" 11312_3 CDM 360 RC 11312 HCPCS outpatient 322 241.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 273.93 85.07 999999999 251.16 305.9 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 1.1 TO 2.0 CM" 11312_3 CDM 360 RC 11312 HCPCS outpatient 322 241.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 273.93 85.07 999999999 251.16 305.9 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 1.1 TO 2.0 CM" 11312_3 CDM 360 RC 11312 HCPCS outpatient 322 241.5 MOLINA MCAID MOLINA MCAID 268.55 83.4 999999999 251.16 305.9 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 1.1 TO 2.0 CM" 11312_3 CDM 360 RC 11312 HCPCS outpatient 322 241.5 MOLINA MCR ADV MOLINA MCR ADV 286.58 89 999999999 251.16 305.9 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 1.1 TO 2.0 CM" 11312_3 CDM 360 RC 11312 HCPCS outpatient 322 241.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 286.58 89 999999999 251.16 305.9 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 1.1 TO 2.0 CM" 11312_3 CDM 360 RC 11312 HCPCS outpatient 322 241.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 286.58 89 999999999 251.16 305.9 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 1.1 TO 2.0 CM" 11312_3 CDM 360 RC 11312 HCPCS outpatient 322 241.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 289.8 90 999999999 251.16 305.9 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 1.1 TO 2.0 CM" 11312_3 CDM 360 RC 11312 HCPCS outpatient 322 241.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 305.9 95 999999999 251.16 305.9 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 1.1 TO 2.0 CM" 11312_3 CDM 360 RC 11312 HCPCS outpatient 322 241.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 305.9 95 999999999 251.16 305.9 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 1.1 TO 2.0 CM" 11312_3 CDM 360 RC 11312 HCPCS outpatient 322 241.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 286.58 89 999999999 251.16 305.9 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 1.1 TO 2.0 CM" 11312_3 CDM 360 RC 11312 HCPCS outpatient 322 241.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 283.36 88 999999999 251.16 305.9 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 1.1 TO 2.0 CM" 11312_3 CDM 360 RC 11312 HCPCS outpatient 322 241.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 286.58 89 999999999 251.16 305.9 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER OVER 2.0 CM" 11313_3 CDM 360 RC 11313 HCPCS outpatient 376 282 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 338.4 999999999 293.28 357.2 case rate "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER OVER 2.0 CM" 11313_3 CDM 360 RC 11313 HCPCS outpatient 376 282 AETNA MCR ADV AETNA MCR ADV 293.28 78 999999999 293.28 357.2 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER OVER 2.0 CM" 11313_3 CDM 360 RC 11313 HCPCS outpatient 376 282 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 329.26 87.57 999999999 293.28 357.2 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER OVER 2.0 CM" 11313_3 CDM 360 RC 11313 HCPCS outpatient 376 282 COORDINATED CARE MCAID COORDINATED CARE MCAID 319.86 85.07 999999999 293.28 357.2 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER OVER 2.0 CM" 11313_3 CDM 360 RC 11313 HCPCS outpatient 376 282 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 319.86 85.07 999999999 293.28 357.2 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER OVER 2.0 CM" 11313_3 CDM 360 RC 11313 HCPCS outpatient 376 282 MOLINA MCAID MOLINA MCAID 313.58 83.4 999999999 293.28 357.2 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER OVER 2.0 CM" 11313_3 CDM 360 RC 11313 HCPCS outpatient 376 282 MOLINA MCR ADV MOLINA MCR ADV 334.64 89 999999999 293.28 357.2 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER OVER 2.0 CM" 11313_3 CDM 360 RC 11313 HCPCS outpatient 376 282 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 334.64 89 999999999 293.28 357.2 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER OVER 2.0 CM" 11313_3 CDM 360 RC 11313 HCPCS outpatient 376 282 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 334.64 89 999999999 293.28 357.2 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER OVER 2.0 CM" 11313_3 CDM 360 RC 11313 HCPCS outpatient 376 282 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 338.4 90 999999999 293.28 357.2 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER OVER 2.0 CM" 11313_3 CDM 360 RC 11313 HCPCS outpatient 376 282 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 357.2 95 999999999 293.28 357.2 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER OVER 2.0 CM" 11313_3 CDM 360 RC 11313 HCPCS outpatient 376 282 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 357.2 95 999999999 293.28 357.2 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER OVER 2.0 CM" 11313_3 CDM 360 RC 11313 HCPCS outpatient 376 282 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 334.64 89 999999999 293.28 357.2 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER OVER 2.0 CM" 11313_3 CDM 360 RC 11313 HCPCS outpatient 376 282 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 330.88 88 999999999 293.28 357.2 percent of total billed charges "SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER OVER 2.0 CM" 11313_3 CDM 360 RC 11313 HCPCS outpatient 376 282 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 334.64 89 999999999 293.28 357.2 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS" 11400_3 CDM 360 RC 11400 HCPCS outpatient 265 198.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 238.5 999999999 206.7 251.75 case rate "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS" 11400_3 CDM 360 RC 11400 HCPCS outpatient 265 198.75 AETNA MCR ADV AETNA MCR ADV 206.7 78 999999999 206.7 251.75 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS" 11400_3 CDM 360 RC 11400 HCPCS outpatient 265 198.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 232.06 87.57 999999999 206.7 251.75 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS" 11400_3 CDM 360 RC 11400 HCPCS outpatient 265 198.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 225.44 85.07 999999999 206.7 251.75 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS" 11400_3 CDM 360 RC 11400 HCPCS outpatient 265 198.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 225.44 85.07 999999999 206.7 251.75 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS" 11400_3 CDM 360 RC 11400 HCPCS outpatient 265 198.75 MOLINA MCAID MOLINA MCAID 221.01 83.4 999999999 206.7 251.75 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS" 11400_3 CDM 360 RC 11400 HCPCS outpatient 265 198.75 MOLINA MCR ADV MOLINA MCR ADV 235.85 89 999999999 206.7 251.75 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS" 11400_3 CDM 360 RC 11400 HCPCS outpatient 265 198.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 235.85 89 999999999 206.7 251.75 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS" 11400_3 CDM 360 RC 11400 HCPCS outpatient 265 198.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 235.85 89 999999999 206.7 251.75 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS" 11400_3 CDM 360 RC 11400 HCPCS outpatient 265 198.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 238.5 90 999999999 206.7 251.75 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS" 11400_3 CDM 360 RC 11400 HCPCS outpatient 265 198.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 251.75 95 999999999 206.7 251.75 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS" 11400_3 CDM 360 RC 11400 HCPCS outpatient 265 198.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 251.75 95 999999999 206.7 251.75 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS" 11400_3 CDM 360 RC 11400 HCPCS outpatient 265 198.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 235.85 89 999999999 206.7 251.75 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS" 11400_3 CDM 360 RC 11400 HCPCS outpatient 265 198.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 233.2 88 999999999 206.7 251.75 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS" 11400_3 CDM 360 RC 11400 HCPCS outpatient 265 198.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 235.85 89 999999999 206.7 251.75 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11401_3 CDM 360 RC 11401 HCPCS outpatient 323 242.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 290.7 999999999 251.94 306.85 case rate "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11401_3 CDM 360 RC 11401 HCPCS outpatient 323 242.25 AETNA MCR ADV AETNA MCR ADV 251.94 78 999999999 251.94 306.85 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11401_3 CDM 360 RC 11401 HCPCS outpatient 323 242.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 282.85 87.57 999999999 251.94 306.85 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11401_3 CDM 360 RC 11401 HCPCS outpatient 323 242.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 274.78 85.07 999999999 251.94 306.85 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11401_3 CDM 360 RC 11401 HCPCS outpatient 323 242.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 274.78 85.07 999999999 251.94 306.85 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11401_3 CDM 360 RC 11401 HCPCS outpatient 323 242.25 MOLINA MCAID MOLINA MCAID 269.38 83.4 999999999 251.94 306.85 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11401_3 CDM 360 RC 11401 HCPCS outpatient 323 242.25 MOLINA MCR ADV MOLINA MCR ADV 287.47 89 999999999 251.94 306.85 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11401_3 CDM 360 RC 11401 HCPCS outpatient 323 242.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 287.47 89 999999999 251.94 306.85 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11401_3 CDM 360 RC 11401 HCPCS outpatient 323 242.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 287.47 89 999999999 251.94 306.85 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11401_3 CDM 360 RC 11401 HCPCS outpatient 323 242.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 290.7 90 999999999 251.94 306.85 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11401_3 CDM 360 RC 11401 HCPCS outpatient 323 242.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 306.85 95 999999999 251.94 306.85 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11401_3 CDM 360 RC 11401 HCPCS outpatient 323 242.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 306.85 95 999999999 251.94 306.85 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11401_3 CDM 360 RC 11401 HCPCS outpatient 323 242.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 287.47 89 999999999 251.94 306.85 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11401_3 CDM 360 RC 11401 HCPCS outpatient 323 242.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 284.24 88 999999999 251.94 306.85 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11401_3 CDM 360 RC 11401 HCPCS outpatient 323 242.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 287.47 89 999999999 251.94 306.85 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11402_3 CDM 360 RC 11402 HCPCS outpatient 356 267 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 320.4 999999999 277.68 338.2 case rate "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11402_3 CDM 360 RC 11402 HCPCS outpatient 356 267 AETNA MCR ADV AETNA MCR ADV 277.68 78 999999999 277.68 338.2 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11402_3 CDM 360 RC 11402 HCPCS outpatient 356 267 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 311.75 87.57 999999999 277.68 338.2 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11402_3 CDM 360 RC 11402 HCPCS outpatient 356 267 COORDINATED CARE MCAID COORDINATED CARE MCAID 302.85 85.07 999999999 277.68 338.2 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11402_3 CDM 360 RC 11402 HCPCS outpatient 356 267 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 302.85 85.07 999999999 277.68 338.2 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11402_3 CDM 360 RC 11402 HCPCS outpatient 356 267 MOLINA MCAID MOLINA MCAID 296.9 83.4 999999999 277.68 338.2 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11402_3 CDM 360 RC 11402 HCPCS outpatient 356 267 MOLINA MCR ADV MOLINA MCR ADV 316.84 89 999999999 277.68 338.2 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11402_3 CDM 360 RC 11402 HCPCS outpatient 356 267 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 316.84 89 999999999 277.68 338.2 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11402_3 CDM 360 RC 11402 HCPCS outpatient 356 267 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 316.84 89 999999999 277.68 338.2 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11402_3 CDM 360 RC 11402 HCPCS outpatient 356 267 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 320.4 90 999999999 277.68 338.2 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11402_3 CDM 360 RC 11402 HCPCS outpatient 356 267 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 338.2 95 999999999 277.68 338.2 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11402_3 CDM 360 RC 11402 HCPCS outpatient 356 267 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 338.2 95 999999999 277.68 338.2 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11402_3 CDM 360 RC 11402 HCPCS outpatient 356 267 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 316.84 89 999999999 277.68 338.2 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11402_3 CDM 360 RC 11402 HCPCS outpatient 356 267 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 313.28 88 999999999 277.68 338.2 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11402_3 CDM 360 RC 11402 HCPCS outpatient 356 267 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 316.84 89 999999999 277.68 338.2 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM" 11403_3 CDM 360 RC 11403 HCPCS outpatient 406 304.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 365.4 999999999 316.68 385.7 case rate "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM" 11403_3 CDM 360 RC 11403 HCPCS outpatient 406 304.5 AETNA MCR ADV AETNA MCR ADV 316.68 78 999999999 316.68 385.7 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM" 11403_3 CDM 360 RC 11403 HCPCS outpatient 406 304.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 355.53 87.57 999999999 316.68 385.7 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM" 11403_3 CDM 360 RC 11403 HCPCS outpatient 406 304.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 345.38 85.07 999999999 316.68 385.7 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM" 11403_3 CDM 360 RC 11403 HCPCS outpatient 406 304.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 345.38 85.07 999999999 316.68 385.7 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM" 11403_3 CDM 360 RC 11403 HCPCS outpatient 406 304.5 MOLINA MCAID MOLINA MCAID 338.6 83.4 999999999 316.68 385.7 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM" 11403_3 CDM 360 RC 11403 HCPCS outpatient 406 304.5 MOLINA MCR ADV MOLINA MCR ADV 361.34 89 999999999 316.68 385.7 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM" 11403_3 CDM 360 RC 11403 HCPCS outpatient 406 304.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 361.34 89 999999999 316.68 385.7 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM" 11403_3 CDM 360 RC 11403 HCPCS outpatient 406 304.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 361.34 89 999999999 316.68 385.7 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM" 11403_3 CDM 360 RC 11403 HCPCS outpatient 406 304.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 365.4 90 999999999 316.68 385.7 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM" 11403_3 CDM 360 RC 11403 HCPCS outpatient 406 304.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 385.7 95 999999999 316.68 385.7 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM" 11403_3 CDM 360 RC 11403 HCPCS outpatient 406 304.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 385.7 95 999999999 316.68 385.7 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM" 11403_3 CDM 360 RC 11403 HCPCS outpatient 406 304.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 361.34 89 999999999 316.68 385.7 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM" 11403_3 CDM 360 RC 11403 HCPCS outpatient 406 304.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 357.28 88 999999999 316.68 385.7 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM" 11403_3 CDM 360 RC 11403 HCPCS outpatient 406 304.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 361.34 89 999999999 316.68 385.7 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM" 11404_3 CDM 360 RC 11404 HCPCS outpatient 462 346.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 415.8 999999999 360.36 438.9 case rate "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM" 11404_3 CDM 360 RC 11404 HCPCS outpatient 462 346.5 AETNA MCR ADV AETNA MCR ADV 360.36 78 999999999 360.36 438.9 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM" 11404_3 CDM 360 RC 11404 HCPCS outpatient 462 346.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 404.57 87.57 999999999 360.36 438.9 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM" 11404_3 CDM 360 RC 11404 HCPCS outpatient 462 346.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 393.02 85.07 999999999 360.36 438.9 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM" 11404_3 CDM 360 RC 11404 HCPCS outpatient 462 346.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 393.02 85.07 999999999 360.36 438.9 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM" 11404_3 CDM 360 RC 11404 HCPCS outpatient 462 346.5 MOLINA MCAID MOLINA MCAID 385.31 83.4 999999999 360.36 438.9 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM" 11404_3 CDM 360 RC 11404 HCPCS outpatient 462 346.5 MOLINA MCR ADV MOLINA MCR ADV 411.18 89 999999999 360.36 438.9 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM" 11404_3 CDM 360 RC 11404 HCPCS outpatient 462 346.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 411.18 89 999999999 360.36 438.9 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM" 11404_3 CDM 360 RC 11404 HCPCS outpatient 462 346.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 411.18 89 999999999 360.36 438.9 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM" 11404_3 CDM 360 RC 11404 HCPCS outpatient 462 346.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 415.8 90 999999999 360.36 438.9 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM" 11404_3 CDM 360 RC 11404 HCPCS outpatient 462 346.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 438.9 95 999999999 360.36 438.9 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM" 11404_3 CDM 360 RC 11404 HCPCS outpatient 462 346.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 438.9 95 999999999 360.36 438.9 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM" 11404_3 CDM 360 RC 11404 HCPCS outpatient 462 346.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 411.18 89 999999999 360.36 438.9 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM" 11404_3 CDM 360 RC 11404 HCPCS outpatient 462 346.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 406.56 88 999999999 360.36 438.9 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM" 11404_3 CDM 360 RC 11404 HCPCS outpatient 462 346.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 411.18 89 999999999 360.36 438.9 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER OVER 4.0 CM" 11406_3 CDM 360 RC 11406 HCPCS outpatient 652 489 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 586.8 999999999 508.56 619.4 case rate "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER OVER 4.0 CM" 11406_3 CDM 360 RC 11406 HCPCS outpatient 652 489 AETNA MCR ADV AETNA MCR ADV 508.56 78 999999999 508.56 619.4 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER OVER 4.0 CM" 11406_3 CDM 360 RC 11406 HCPCS outpatient 652 489 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 570.96 87.57 999999999 508.56 619.4 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER OVER 4.0 CM" 11406_3 CDM 360 RC 11406 HCPCS outpatient 652 489 COORDINATED CARE MCAID COORDINATED CARE MCAID 554.66 85.07 999999999 508.56 619.4 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER OVER 4.0 CM" 11406_3 CDM 360 RC 11406 HCPCS outpatient 652 489 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 554.66 85.07 999999999 508.56 619.4 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER OVER 4.0 CM" 11406_3 CDM 360 RC 11406 HCPCS outpatient 652 489 MOLINA MCAID MOLINA MCAID 543.77 83.4 999999999 508.56 619.4 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER OVER 4.0 CM" 11406_3 CDM 360 RC 11406 HCPCS outpatient 652 489 MOLINA MCR ADV MOLINA MCR ADV 580.28 89 999999999 508.56 619.4 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER OVER 4.0 CM" 11406_3 CDM 360 RC 11406 HCPCS outpatient 652 489 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 580.28 89 999999999 508.56 619.4 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER OVER 4.0 CM" 11406_3 CDM 360 RC 11406 HCPCS outpatient 652 489 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 580.28 89 999999999 508.56 619.4 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER OVER 4.0 CM" 11406_3 CDM 360 RC 11406 HCPCS outpatient 652 489 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 586.8 90 999999999 508.56 619.4 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER OVER 4.0 CM" 11406_3 CDM 360 RC 11406 HCPCS outpatient 652 489 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 619.4 95 999999999 508.56 619.4 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER OVER 4.0 CM" 11406_3 CDM 360 RC 11406 HCPCS outpatient 652 489 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 619.4 95 999999999 508.56 619.4 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER OVER 4.0 CM" 11406_3 CDM 360 RC 11406 HCPCS outpatient 652 489 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 580.28 89 999999999 508.56 619.4 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER OVER 4.0 CM" 11406_3 CDM 360 RC 11406 HCPCS outpatient 652 489 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 573.76 88 999999999 508.56 619.4 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER OVER 4.0 CM" 11406_3 CDM 360 RC 11406 HCPCS outpatient 652 489 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 580.28 89 999999999 508.56 619.4 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS" 11420_3 CDM 360 RC 11420 HCPCS outpatient 265 198.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 238.5 999999999 206.7 251.75 case rate "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS" 11420_3 CDM 360 RC 11420 HCPCS outpatient 265 198.75 AETNA MCR ADV AETNA MCR ADV 206.7 78 999999999 206.7 251.75 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS" 11420_3 CDM 360 RC 11420 HCPCS outpatient 265 198.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 232.06 87.57 999999999 206.7 251.75 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS" 11420_3 CDM 360 RC 11420 HCPCS outpatient 265 198.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 225.44 85.07 999999999 206.7 251.75 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS" 11420_3 CDM 360 RC 11420 HCPCS outpatient 265 198.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 225.44 85.07 999999999 206.7 251.75 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS" 11420_3 CDM 360 RC 11420 HCPCS outpatient 265 198.75 MOLINA MCAID MOLINA MCAID 221.01 83.4 999999999 206.7 251.75 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS" 11420_3 CDM 360 RC 11420 HCPCS outpatient 265 198.75 MOLINA MCR ADV MOLINA MCR ADV 235.85 89 999999999 206.7 251.75 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS" 11420_3 CDM 360 RC 11420 HCPCS outpatient 265 198.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 235.85 89 999999999 206.7 251.75 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS" 11420_3 CDM 360 RC 11420 HCPCS outpatient 265 198.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 235.85 89 999999999 206.7 251.75 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS" 11420_3 CDM 360 RC 11420 HCPCS outpatient 265 198.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 238.5 90 999999999 206.7 251.75 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS" 11420_3 CDM 360 RC 11420 HCPCS outpatient 265 198.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 251.75 95 999999999 206.7 251.75 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS" 11420_3 CDM 360 RC 11420 HCPCS outpatient 265 198.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 251.75 95 999999999 206.7 251.75 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS" 11420_3 CDM 360 RC 11420 HCPCS outpatient 265 198.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 235.85 89 999999999 206.7 251.75 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS" 11420_3 CDM 360 RC 11420 HCPCS outpatient 265 198.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 233.2 88 999999999 206.7 251.75 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS" 11420_3 CDM 360 RC 11420 HCPCS outpatient 265 198.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 235.85 89 999999999 206.7 251.75 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM" 11421_3 CDM 360 RC 11421 HCPCS outpatient 330 247.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 297 999999999 257.4 313.5 case rate "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM" 11421_3 CDM 360 RC 11421 HCPCS outpatient 330 247.5 AETNA MCR ADV AETNA MCR ADV 257.4 78 999999999 257.4 313.5 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM" 11421_3 CDM 360 RC 11421 HCPCS outpatient 330 247.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 288.98 87.57 999999999 257.4 313.5 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM" 11421_3 CDM 360 RC 11421 HCPCS outpatient 330 247.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 280.73 85.07 999999999 257.4 313.5 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM" 11421_3 CDM 360 RC 11421 HCPCS outpatient 330 247.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 280.73 85.07 999999999 257.4 313.5 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM" 11421_3 CDM 360 RC 11421 HCPCS outpatient 330 247.5 MOLINA MCAID MOLINA MCAID 275.22 83.4 999999999 257.4 313.5 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM" 11421_3 CDM 360 RC 11421 HCPCS outpatient 330 247.5 MOLINA MCR ADV MOLINA MCR ADV 293.7 89 999999999 257.4 313.5 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM" 11421_3 CDM 360 RC 11421 HCPCS outpatient 330 247.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 293.7 89 999999999 257.4 313.5 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM" 11421_3 CDM 360 RC 11421 HCPCS outpatient 330 247.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 293.7 89 999999999 257.4 313.5 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM" 11421_3 CDM 360 RC 11421 HCPCS outpatient 330 247.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 297 90 999999999 257.4 313.5 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM" 11421_3 CDM 360 RC 11421 HCPCS outpatient 330 247.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 313.5 95 999999999 257.4 313.5 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM" 11421_3 CDM 360 RC 11421 HCPCS outpatient 330 247.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 313.5 95 999999999 257.4 313.5 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM" 11421_3 CDM 360 RC 11421 HCPCS outpatient 330 247.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 293.7 89 999999999 257.4 313.5 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM" 11421_3 CDM 360 RC 11421 HCPCS outpatient 330 247.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 290.4 88 999999999 257.4 313.5 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM" 11421_3 CDM 360 RC 11421 HCPCS outpatient 330 247.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 293.7 89 999999999 257.4 313.5 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM" 11422_3 CDM 360 RC 11422 HCPCS outpatient 370 277.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 333 999999999 288.6 351.5 case rate "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM" 11422_3 CDM 360 RC 11422 HCPCS outpatient 370 277.5 AETNA MCR ADV AETNA MCR ADV 288.6 78 999999999 288.6 351.5 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM" 11422_3 CDM 360 RC 11422 HCPCS outpatient 370 277.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 324.01 87.57 999999999 288.6 351.5 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM" 11422_3 CDM 360 RC 11422 HCPCS outpatient 370 277.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 314.76 85.07 999999999 288.6 351.5 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM" 11422_3 CDM 360 RC 11422 HCPCS outpatient 370 277.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 314.76 85.07 999999999 288.6 351.5 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM" 11422_3 CDM 360 RC 11422 HCPCS outpatient 370 277.5 MOLINA MCAID MOLINA MCAID 308.58 83.4 999999999 288.6 351.5 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM" 11422_3 CDM 360 RC 11422 HCPCS outpatient 370 277.5 MOLINA MCR ADV MOLINA MCR ADV 329.3 89 999999999 288.6 351.5 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM" 11422_3 CDM 360 RC 11422 HCPCS outpatient 370 277.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 329.3 89 999999999 288.6 351.5 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM" 11422_3 CDM 360 RC 11422 HCPCS outpatient 370 277.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 329.3 89 999999999 288.6 351.5 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM" 11422_3 CDM 360 RC 11422 HCPCS outpatient 370 277.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 333 90 999999999 288.6 351.5 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM" 11422_3 CDM 360 RC 11422 HCPCS outpatient 370 277.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 351.5 95 999999999 288.6 351.5 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM" 11422_3 CDM 360 RC 11422 HCPCS outpatient 370 277.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 351.5 95 999999999 288.6 351.5 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM" 11422_3 CDM 360 RC 11422 HCPCS outpatient 370 277.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 329.3 89 999999999 288.6 351.5 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM" 11422_3 CDM 360 RC 11422 HCPCS outpatient 370 277.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 325.6 88 999999999 288.6 351.5 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM" 11422_3 CDM 360 RC 11422 HCPCS outpatient 370 277.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 329.3 89 999999999 288.6 351.5 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM" 11423_3 CDM 360 RC 11423 HCPCS outpatient 422 316.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 379.8 999999999 329.16 400.9 case rate "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM" 11423_3 CDM 360 RC 11423 HCPCS outpatient 422 316.5 AETNA MCR ADV AETNA MCR ADV 329.16 78 999999999 329.16 400.9 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM" 11423_3 CDM 360 RC 11423 HCPCS outpatient 422 316.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 369.55 87.57 999999999 329.16 400.9 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM" 11423_3 CDM 360 RC 11423 HCPCS outpatient 422 316.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 359 85.07 999999999 329.16 400.9 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM" 11423_3 CDM 360 RC 11423 HCPCS outpatient 422 316.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 359 85.07 999999999 329.16 400.9 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM" 11423_3 CDM 360 RC 11423 HCPCS outpatient 422 316.5 MOLINA MCAID MOLINA MCAID 351.95 83.4 999999999 329.16 400.9 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM" 11423_3 CDM 360 RC 11423 HCPCS outpatient 422 316.5 MOLINA MCR ADV MOLINA MCR ADV 375.58 89 999999999 329.16 400.9 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM" 11423_3 CDM 360 RC 11423 HCPCS outpatient 422 316.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 375.58 89 999999999 329.16 400.9 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM" 11423_3 CDM 360 RC 11423 HCPCS outpatient 422 316.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 375.58 89 999999999 329.16 400.9 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM" 11423_3 CDM 360 RC 11423 HCPCS outpatient 422 316.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 379.8 90 999999999 329.16 400.9 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM" 11423_3 CDM 360 RC 11423 HCPCS outpatient 422 316.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 400.9 95 999999999 329.16 400.9 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM" 11423_3 CDM 360 RC 11423 HCPCS outpatient 422 316.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 400.9 95 999999999 329.16 400.9 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM" 11423_3 CDM 360 RC 11423 HCPCS outpatient 422 316.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 375.58 89 999999999 329.16 400.9 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM" 11423_3 CDM 360 RC 11423 HCPCS outpatient 422 316.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 371.36 88 999999999 329.16 400.9 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM" 11423_3 CDM 360 RC 11423 HCPCS outpatient 422 316.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 375.58 89 999999999 329.16 400.9 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM" 11424_3 CDM 360 RC 11424 HCPCS outpatient 480 360 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 432 999999999 374.4 456 case rate "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM" 11424_3 CDM 360 RC 11424 HCPCS outpatient 480 360 AETNA MCR ADV AETNA MCR ADV 374.4 78 999999999 374.4 456 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM" 11424_3 CDM 360 RC 11424 HCPCS outpatient 480 360 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 420.34 87.57 999999999 374.4 456 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM" 11424_3 CDM 360 RC 11424 HCPCS outpatient 480 360 COORDINATED CARE MCAID COORDINATED CARE MCAID 408.34 85.07 999999999 374.4 456 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM" 11424_3 CDM 360 RC 11424 HCPCS outpatient 480 360 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 408.34 85.07 999999999 374.4 456 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM" 11424_3 CDM 360 RC 11424 HCPCS outpatient 480 360 MOLINA MCAID MOLINA MCAID 400.32 83.4 999999999 374.4 456 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM" 11424_3 CDM 360 RC 11424 HCPCS outpatient 480 360 MOLINA MCR ADV MOLINA MCR ADV 427.2 89 999999999 374.4 456 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM" 11424_3 CDM 360 RC 11424 HCPCS outpatient 480 360 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 427.2 89 999999999 374.4 456 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM" 11424_3 CDM 360 RC 11424 HCPCS outpatient 480 360 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 427.2 89 999999999 374.4 456 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM" 11424_3 CDM 360 RC 11424 HCPCS outpatient 480 360 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 432 90 999999999 374.4 456 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM" 11424_3 CDM 360 RC 11424 HCPCS outpatient 480 360 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 456 95 999999999 374.4 456 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM" 11424_3 CDM 360 RC 11424 HCPCS outpatient 480 360 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 456 95 999999999 374.4 456 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM" 11424_3 CDM 360 RC 11424 HCPCS outpatient 480 360 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 427.2 89 999999999 374.4 456 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM" 11424_3 CDM 360 RC 11424 HCPCS outpatient 480 360 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 422.4 88 999999999 374.4 456 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM" 11424_3 CDM 360 RC 11424 HCPCS outpatient 480 360 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 427.2 89 999999999 374.4 456 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM" 11426_3 CDM 360 RC 11426 HCPCS outpatient 680 510 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 612 999999999 530.4 646 case rate "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM" 11426_3 CDM 360 RC 11426 HCPCS outpatient 680 510 AETNA MCR ADV AETNA MCR ADV 530.4 78 999999999 530.4 646 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM" 11426_3 CDM 360 RC 11426 HCPCS outpatient 680 510 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 595.48 87.57 999999999 530.4 646 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM" 11426_3 CDM 360 RC 11426 HCPCS outpatient 680 510 COORDINATED CARE MCAID COORDINATED CARE MCAID 578.48 85.07 999999999 530.4 646 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM" 11426_3 CDM 360 RC 11426 HCPCS outpatient 680 510 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 578.48 85.07 999999999 530.4 646 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM" 11426_3 CDM 360 RC 11426 HCPCS outpatient 680 510 MOLINA MCAID MOLINA MCAID 567.12 83.4 999999999 530.4 646 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM" 11426_3 CDM 360 RC 11426 HCPCS outpatient 680 510 MOLINA MCR ADV MOLINA MCR ADV 605.2 89 999999999 530.4 646 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM" 11426_3 CDM 360 RC 11426 HCPCS outpatient 680 510 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 605.2 89 999999999 530.4 646 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM" 11426_3 CDM 360 RC 11426 HCPCS outpatient 680 510 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 605.2 89 999999999 530.4 646 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM" 11426_3 CDM 360 RC 11426 HCPCS outpatient 680 510 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 612 90 999999999 530.4 646 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM" 11426_3 CDM 360 RC 11426 HCPCS outpatient 680 510 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 646 95 999999999 530.4 646 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM" 11426_3 CDM 360 RC 11426 HCPCS outpatient 680 510 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 646 95 999999999 530.4 646 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM" 11426_3 CDM 360 RC 11426 HCPCS outpatient 680 510 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 605.2 89 999999999 530.4 646 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM" 11426_3 CDM 360 RC 11426 HCPCS outpatient 680 510 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 598.4 88 999999999 530.4 646 percent of total billed charges "EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM" 11426_3 CDM 360 RC 11426 HCPCS outpatient 680 510 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 605.2 89 999999999 530.4 646 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.5 CM OR LESS" 11440_3 CDM 360 RC 11440 HCPCS outpatient 298 223.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 268.2 999999999 232.44 283.1 case rate "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.5 CM OR LESS" 11440_3 CDM 360 RC 11440 HCPCS outpatient 298 223.5 AETNA MCR ADV AETNA MCR ADV 232.44 78 999999999 232.44 283.1 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.5 CM OR LESS" 11440_3 CDM 360 RC 11440 HCPCS outpatient 298 223.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 260.96 87.57 999999999 232.44 283.1 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.5 CM OR LESS" 11440_3 CDM 360 RC 11440 HCPCS outpatient 298 223.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 253.51 85.07 999999999 232.44 283.1 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.5 CM OR LESS" 11440_3 CDM 360 RC 11440 HCPCS outpatient 298 223.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 253.51 85.07 999999999 232.44 283.1 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.5 CM OR LESS" 11440_3 CDM 360 RC 11440 HCPCS outpatient 298 223.5 MOLINA MCAID MOLINA MCAID 248.53 83.4 999999999 232.44 283.1 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.5 CM OR LESS" 11440_3 CDM 360 RC 11440 HCPCS outpatient 298 223.5 MOLINA MCR ADV MOLINA MCR ADV 265.22 89 999999999 232.44 283.1 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.5 CM OR LESS" 11440_3 CDM 360 RC 11440 HCPCS outpatient 298 223.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 265.22 89 999999999 232.44 283.1 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.5 CM OR LESS" 11440_3 CDM 360 RC 11440 HCPCS outpatient 298 223.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 265.22 89 999999999 232.44 283.1 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.5 CM OR LESS" 11440_3 CDM 360 RC 11440 HCPCS outpatient 298 223.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 268.2 90 999999999 232.44 283.1 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.5 CM OR LESS" 11440_3 CDM 360 RC 11440 HCPCS outpatient 298 223.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 283.1 95 999999999 232.44 283.1 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.5 CM OR LESS" 11440_3 CDM 360 RC 11440 HCPCS outpatient 298 223.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 283.1 95 999999999 232.44 283.1 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.5 CM OR LESS" 11440_3 CDM 360 RC 11440 HCPCS outpatient 298 223.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 265.22 89 999999999 232.44 283.1 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.5 CM OR LESS" 11440_3 CDM 360 RC 11440 HCPCS outpatient 298 223.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 262.24 88 999999999 232.44 283.1 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.5 CM OR LESS" 11440_3 CDM 360 RC 11440 HCPCS outpatient 298 223.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 265.22 89 999999999 232.44 283.1 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.6 TO 1.0 CM" 11441_3 CDM 360 RC 11441 HCPCS outpatient 360 270 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 324 999999999 280.8 342 case rate "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.6 TO 1.0 CM" 11441_3 CDM 360 RC 11441 HCPCS outpatient 360 270 AETNA MCR ADV AETNA MCR ADV 280.8 78 999999999 280.8 342 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.6 TO 1.0 CM" 11441_3 CDM 360 RC 11441 HCPCS outpatient 360 270 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 315.25 87.57 999999999 280.8 342 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.6 TO 1.0 CM" 11441_3 CDM 360 RC 11441 HCPCS outpatient 360 270 COORDINATED CARE MCAID COORDINATED CARE MCAID 306.25 85.07 999999999 280.8 342 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.6 TO 1.0 CM" 11441_3 CDM 360 RC 11441 HCPCS outpatient 360 270 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 306.25 85.07 999999999 280.8 342 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.6 TO 1.0 CM" 11441_3 CDM 360 RC 11441 HCPCS outpatient 360 270 MOLINA MCAID MOLINA MCAID 300.24 83.4 999999999 280.8 342 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.6 TO 1.0 CM" 11441_3 CDM 360 RC 11441 HCPCS outpatient 360 270 MOLINA MCR ADV MOLINA MCR ADV 320.4 89 999999999 280.8 342 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.6 TO 1.0 CM" 11441_3 CDM 360 RC 11441 HCPCS outpatient 360 270 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 320.4 89 999999999 280.8 342 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.6 TO 1.0 CM" 11441_3 CDM 360 RC 11441 HCPCS outpatient 360 270 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 320.4 89 999999999 280.8 342 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.6 TO 1.0 CM" 11441_3 CDM 360 RC 11441 HCPCS outpatient 360 270 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 324 90 999999999 280.8 342 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.6 TO 1.0 CM" 11441_3 CDM 360 RC 11441 HCPCS outpatient 360 270 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 342 95 999999999 280.8 342 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.6 TO 1.0 CM" 11441_3 CDM 360 RC 11441 HCPCS outpatient 360 270 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 342 95 999999999 280.8 342 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.6 TO 1.0 CM" 11441_3 CDM 360 RC 11441 HCPCS outpatient 360 270 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 320.4 89 999999999 280.8 342 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.6 TO 1.0 CM" 11441_3 CDM 360 RC 11441 HCPCS outpatient 360 270 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 316.8 88 999999999 280.8 342 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.6 TO 1.0 CM" 11441_3 CDM 360 RC 11441 HCPCS outpatient 360 270 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 320.4 89 999999999 280.8 342 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 1.1 TO 2.0 CM" 11442_3 CDM 360 RC 11442 HCPCS outpatient 400 300 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 360 999999999 312 380 case rate "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 1.1 TO 2.0 CM" 11442_3 CDM 360 RC 11442 HCPCS outpatient 400 300 AETNA MCR ADV AETNA MCR ADV 312 78 999999999 312 380 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 1.1 TO 2.0 CM" 11442_3 CDM 360 RC 11442 HCPCS outpatient 400 300 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 350.28 87.57 999999999 312 380 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 1.1 TO 2.0 CM" 11442_3 CDM 360 RC 11442 HCPCS outpatient 400 300 COORDINATED CARE MCAID COORDINATED CARE MCAID 340.28 85.07 999999999 312 380 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 1.1 TO 2.0 CM" 11442_3 CDM 360 RC 11442 HCPCS outpatient 400 300 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 340.28 85.07 999999999 312 380 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 1.1 TO 2.0 CM" 11442_3 CDM 360 RC 11442 HCPCS outpatient 400 300 MOLINA MCAID MOLINA MCAID 333.6 83.4 999999999 312 380 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 1.1 TO 2.0 CM" 11442_3 CDM 360 RC 11442 HCPCS outpatient 400 300 MOLINA MCR ADV MOLINA MCR ADV 356 89 999999999 312 380 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 1.1 TO 2.0 CM" 11442_3 CDM 360 RC 11442 HCPCS outpatient 400 300 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 356 89 999999999 312 380 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 1.1 TO 2.0 CM" 11442_3 CDM 360 RC 11442 HCPCS outpatient 400 300 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 356 89 999999999 312 380 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 1.1 TO 2.0 CM" 11442_3 CDM 360 RC 11442 HCPCS outpatient 400 300 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 360 90 999999999 312 380 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 1.1 TO 2.0 CM" 11442_3 CDM 360 RC 11442 HCPCS outpatient 400 300 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 380 95 999999999 312 380 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 1.1 TO 2.0 CM" 11442_3 CDM 360 RC 11442 HCPCS outpatient 400 300 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 380 95 999999999 312 380 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 1.1 TO 2.0 CM" 11442_3 CDM 360 RC 11442 HCPCS outpatient 400 300 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 356 89 999999999 312 380 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 1.1 TO 2.0 CM" 11442_3 CDM 360 RC 11442 HCPCS outpatient 400 300 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 352 88 999999999 312 380 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 1.1 TO 2.0 CM" 11442_3 CDM 360 RC 11442 HCPCS outpatient 400 300 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 356 89 999999999 312 380 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 2.1 TO 3.0 CM" 11443_3 CDM 360 RC 11443 HCPCS outpatient 468 351 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 421.2 999999999 365.04 444.6 case rate "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 2.1 TO 3.0 CM" 11443_3 CDM 360 RC 11443 HCPCS outpatient 468 351 AETNA MCR ADV AETNA MCR ADV 365.04 78 999999999 365.04 444.6 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 2.1 TO 3.0 CM" 11443_3 CDM 360 RC 11443 HCPCS outpatient 468 351 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 409.83 87.57 999999999 365.04 444.6 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 2.1 TO 3.0 CM" 11443_3 CDM 360 RC 11443 HCPCS outpatient 468 351 COORDINATED CARE MCAID COORDINATED CARE MCAID 398.13 85.07 999999999 365.04 444.6 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 2.1 TO 3.0 CM" 11443_3 CDM 360 RC 11443 HCPCS outpatient 468 351 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 398.13 85.07 999999999 365.04 444.6 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 2.1 TO 3.0 CM" 11443_3 CDM 360 RC 11443 HCPCS outpatient 468 351 MOLINA MCAID MOLINA MCAID 390.31 83.4 999999999 365.04 444.6 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 2.1 TO 3.0 CM" 11443_3 CDM 360 RC 11443 HCPCS outpatient 468 351 MOLINA MCR ADV MOLINA MCR ADV 416.52 89 999999999 365.04 444.6 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 2.1 TO 3.0 CM" 11443_3 CDM 360 RC 11443 HCPCS outpatient 468 351 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 416.52 89 999999999 365.04 444.6 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 2.1 TO 3.0 CM" 11443_3 CDM 360 RC 11443 HCPCS outpatient 468 351 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 416.52 89 999999999 365.04 444.6 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 2.1 TO 3.0 CM" 11443_3 CDM 360 RC 11443 HCPCS outpatient 468 351 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 421.2 90 999999999 365.04 444.6 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 2.1 TO 3.0 CM" 11443_3 CDM 360 RC 11443 HCPCS outpatient 468 351 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 444.6 95 999999999 365.04 444.6 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 2.1 TO 3.0 CM" 11443_3 CDM 360 RC 11443 HCPCS outpatient 468 351 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 444.6 95 999999999 365.04 444.6 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 2.1 TO 3.0 CM" 11443_3 CDM 360 RC 11443 HCPCS outpatient 468 351 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 416.52 89 999999999 365.04 444.6 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 2.1 TO 3.0 CM" 11443_3 CDM 360 RC 11443 HCPCS outpatient 468 351 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 411.84 88 999999999 365.04 444.6 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 2.1 TO 3.0 CM" 11443_3 CDM 360 RC 11443 HCPCS outpatient 468 351 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 416.52 89 999999999 365.04 444.6 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 3.1 TO 4.0 CM" 11444_3 CDM 360 RC 11444 HCPCS outpatient 580 435 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 522 999999999 452.4 551 case rate "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 3.1 TO 4.0 CM" 11444_3 CDM 360 RC 11444 HCPCS outpatient 580 435 AETNA MCR ADV AETNA MCR ADV 452.4 78 999999999 452.4 551 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 3.1 TO 4.0 CM" 11444_3 CDM 360 RC 11444 HCPCS outpatient 580 435 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 507.91 87.57 999999999 452.4 551 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 3.1 TO 4.0 CM" 11444_3 CDM 360 RC 11444 HCPCS outpatient 580 435 COORDINATED CARE MCAID COORDINATED CARE MCAID 493.41 85.07 999999999 452.4 551 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 3.1 TO 4.0 CM" 11444_3 CDM 360 RC 11444 HCPCS outpatient 580 435 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 493.41 85.07 999999999 452.4 551 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 3.1 TO 4.0 CM" 11444_3 CDM 360 RC 11444 HCPCS outpatient 580 435 MOLINA MCAID MOLINA MCAID 483.72 83.4 999999999 452.4 551 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 3.1 TO 4.0 CM" 11444_3 CDM 360 RC 11444 HCPCS outpatient 580 435 MOLINA MCR ADV MOLINA MCR ADV 516.2 89 999999999 452.4 551 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 3.1 TO 4.0 CM" 11444_3 CDM 360 RC 11444 HCPCS outpatient 580 435 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 516.2 89 999999999 452.4 551 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 3.1 TO 4.0 CM" 11444_3 CDM 360 RC 11444 HCPCS outpatient 580 435 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 516.2 89 999999999 452.4 551 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 3.1 TO 4.0 CM" 11444_3 CDM 360 RC 11444 HCPCS outpatient 580 435 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 522 90 999999999 452.4 551 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 3.1 TO 4.0 CM" 11444_3 CDM 360 RC 11444 HCPCS outpatient 580 435 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 551 95 999999999 452.4 551 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 3.1 TO 4.0 CM" 11444_3 CDM 360 RC 11444 HCPCS outpatient 580 435 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 551 95 999999999 452.4 551 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 3.1 TO 4.0 CM" 11444_3 CDM 360 RC 11444 HCPCS outpatient 580 435 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 516.2 89 999999999 452.4 551 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 3.1 TO 4.0 CM" 11444_3 CDM 360 RC 11444 HCPCS outpatient 580 435 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 510.4 88 999999999 452.4 551 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 3.1 TO 4.0 CM" 11444_3 CDM 360 RC 11444 HCPCS outpatient 580 435 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 516.2 89 999999999 452.4 551 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER OVER 4.0 CM" 11446_3 CDM 360 RC 11446 HCPCS outpatient 788 591 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 709.2 999999999 614.64 748.6 case rate "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER OVER 4.0 CM" 11446_3 CDM 360 RC 11446 HCPCS outpatient 788 591 AETNA MCR ADV AETNA MCR ADV 614.64 78 999999999 614.64 748.6 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER OVER 4.0 CM" 11446_3 CDM 360 RC 11446 HCPCS outpatient 788 591 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 690.05 87.57 999999999 614.64 748.6 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER OVER 4.0 CM" 11446_3 CDM 360 RC 11446 HCPCS outpatient 788 591 COORDINATED CARE MCAID COORDINATED CARE MCAID 670.35 85.07 999999999 614.64 748.6 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER OVER 4.0 CM" 11446_3 CDM 360 RC 11446 HCPCS outpatient 788 591 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 670.35 85.07 999999999 614.64 748.6 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER OVER 4.0 CM" 11446_3 CDM 360 RC 11446 HCPCS outpatient 788 591 MOLINA MCAID MOLINA MCAID 657.19 83.4 999999999 614.64 748.6 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER OVER 4.0 CM" 11446_3 CDM 360 RC 11446 HCPCS outpatient 788 591 MOLINA MCR ADV MOLINA MCR ADV 701.32 89 999999999 614.64 748.6 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER OVER 4.0 CM" 11446_3 CDM 360 RC 11446 HCPCS outpatient 788 591 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 701.32 89 999999999 614.64 748.6 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER OVER 4.0 CM" 11446_3 CDM 360 RC 11446 HCPCS outpatient 788 591 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 701.32 89 999999999 614.64 748.6 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER OVER 4.0 CM" 11446_3 CDM 360 RC 11446 HCPCS outpatient 788 591 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 709.2 90 999999999 614.64 748.6 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER OVER 4.0 CM" 11446_3 CDM 360 RC 11446 HCPCS outpatient 788 591 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 748.6 95 999999999 614.64 748.6 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER OVER 4.0 CM" 11446_3 CDM 360 RC 11446 HCPCS outpatient 788 591 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 748.6 95 999999999 614.64 748.6 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER OVER 4.0 CM" 11446_3 CDM 360 RC 11446 HCPCS outpatient 788 591 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 701.32 89 999999999 614.64 748.6 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER OVER 4.0 CM" 11446_3 CDM 360 RC 11446 HCPCS outpatient 788 591 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 693.44 88 999999999 614.64 748.6 percent of total billed charges "EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER OVER 4.0 CM" 11446_3 CDM 360 RC 11446 HCPCS outpatient 788 591 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 701.32 89 999999999 614.64 748.6 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - HOSPICE 1150000001_1 CDM 115 RC inpatient 226 169.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 203.4 90 999999999 198.88 10619 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - HOSPICE 1150000001_1 CDM 115 RC inpatient 226 169.5 AETNA MCR ADV AETNA MCR ADV 10619 999999999 198.88 10619 per diem ROOM & BOARD - PRIVATE (ONE BED) - HOSPICE 1150000001_1 CDM 115 RC inpatient 226 169.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 421.58 186.54 999999999 198.88 10619 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - HOSPICE 1150000001_1 CDM 115 RC inpatient 226 169.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 409.53 181.21 999999999 198.88 10619 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - HOSPICE 1150000001_1 CDM 115 RC inpatient 226 169.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 409.53 181.21 999999999 198.88 10619 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - HOSPICE 1150000001_1 CDM 115 RC inpatient 226 169.5 MOLINA MCAID MOLINA MCAID 401.51 177.66 999999999 198.88 10619 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - HOSPICE 1150000001_1 CDM 115 RC inpatient 226 169.5 MOLINA MCR ADV MOLINA MCR ADV 8243 999999999 198.88 10619 per diem ROOM & BOARD - PRIVATE (ONE BED) - HOSPICE 1150000001_1 CDM 115 RC inpatient 226 169.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 8243 999999999 198.88 10619 per diem ROOM & BOARD - PRIVATE (ONE BED) - HOSPICE 1150000001_1 CDM 115 RC inpatient 226 169.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 8243 999999999 198.88 10619 per diem ROOM & BOARD - PRIVATE (ONE BED) - HOSPICE 1150000001_1 CDM 115 RC inpatient 226 169.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 203.4 90 999999999 198.88 10619 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - HOSPICE 1150000001_1 CDM 115 RC inpatient 226 169.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 214.7 95 999999999 198.88 10619 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - HOSPICE 1150000001_1 CDM 115 RC inpatient 226 169.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 214.7 95 999999999 198.88 10619 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - HOSPICE 1150000001_1 CDM 115 RC inpatient 226 169.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 8243 999999999 198.88 10619 per diem ROOM & BOARD - PRIVATE (ONE BED) - HOSPICE 1150000001_1 CDM 115 RC inpatient 226 169.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 198.88 88 999999999 198.88 10619 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - HOSPICE 1150000001_1 CDM 115 RC inpatient 226 169.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 7006.55 999999999 198.88 10619 per diem "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS" 11600_3 CDM 360 RC 11600 HCPCS outpatient 408 306 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 367.2 999999999 318.24 387.6 case rate "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS" 11600_3 CDM 360 RC 11600 HCPCS outpatient 408 306 AETNA MCR ADV AETNA MCR ADV 318.24 78 999999999 318.24 387.6 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS" 11600_3 CDM 360 RC 11600 HCPCS outpatient 408 306 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 357.29 87.57 999999999 318.24 387.6 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS" 11600_3 CDM 360 RC 11600 HCPCS outpatient 408 306 COORDINATED CARE MCAID COORDINATED CARE MCAID 347.09 85.07 999999999 318.24 387.6 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS" 11600_3 CDM 360 RC 11600 HCPCS outpatient 408 306 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 347.09 85.07 999999999 318.24 387.6 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS" 11600_3 CDM 360 RC 11600 HCPCS outpatient 408 306 MOLINA MCAID MOLINA MCAID 340.27 83.4 999999999 318.24 387.6 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS" 11600_3 CDM 360 RC 11600 HCPCS outpatient 408 306 MOLINA MCR ADV MOLINA MCR ADV 363.12 89 999999999 318.24 387.6 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS" 11600_3 CDM 360 RC 11600 HCPCS outpatient 408 306 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 363.12 89 999999999 318.24 387.6 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS" 11600_3 CDM 360 RC 11600 HCPCS outpatient 408 306 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 363.12 89 999999999 318.24 387.6 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS" 11600_3 CDM 360 RC 11600 HCPCS outpatient 408 306 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 367.2 90 999999999 318.24 387.6 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS" 11600_3 CDM 360 RC 11600 HCPCS outpatient 408 306 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 387.6 95 999999999 318.24 387.6 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS" 11600_3 CDM 360 RC 11600 HCPCS outpatient 408 306 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 387.6 95 999999999 318.24 387.6 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS" 11600_3 CDM 360 RC 11600 HCPCS outpatient 408 306 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 363.12 89 999999999 318.24 387.6 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS" 11600_3 CDM 360 RC 11600 HCPCS outpatient 408 306 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 359.04 88 999999999 318.24 387.6 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS" 11600_3 CDM 360 RC 11600 HCPCS outpatient 408 306 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 363.12 89 999999999 318.24 387.6 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11601_3 CDM 360 RC 11601 HCPCS outpatient 471 353.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 423.9 999999999 367.38 447.45 case rate "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11601_3 CDM 360 RC 11601 HCPCS outpatient 471 353.25 AETNA MCR ADV AETNA MCR ADV 367.38 78 999999999 367.38 447.45 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11601_3 CDM 360 RC 11601 HCPCS outpatient 471 353.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 412.45 87.57 999999999 367.38 447.45 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11601_3 CDM 360 RC 11601 HCPCS outpatient 471 353.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 400.68 85.07 999999999 367.38 447.45 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11601_3 CDM 360 RC 11601 HCPCS outpatient 471 353.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 400.68 85.07 999999999 367.38 447.45 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11601_3 CDM 360 RC 11601 HCPCS outpatient 471 353.25 MOLINA MCAID MOLINA MCAID 392.81 83.4 999999999 367.38 447.45 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11601_3 CDM 360 RC 11601 HCPCS outpatient 471 353.25 MOLINA MCR ADV MOLINA MCR ADV 419.19 89 999999999 367.38 447.45 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11601_3 CDM 360 RC 11601 HCPCS outpatient 471 353.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 419.19 89 999999999 367.38 447.45 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11601_3 CDM 360 RC 11601 HCPCS outpatient 471 353.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 419.19 89 999999999 367.38 447.45 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11601_3 CDM 360 RC 11601 HCPCS outpatient 471 353.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 423.9 90 999999999 367.38 447.45 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11601_3 CDM 360 RC 11601 HCPCS outpatient 471 353.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 447.45 95 999999999 367.38 447.45 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11601_3 CDM 360 RC 11601 HCPCS outpatient 471 353.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 447.45 95 999999999 367.38 447.45 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11601_3 CDM 360 RC 11601 HCPCS outpatient 471 353.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 419.19 89 999999999 367.38 447.45 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11601_3 CDM 360 RC 11601 HCPCS outpatient 471 353.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 414.48 88 999999999 367.38 447.45 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11601_3 CDM 360 RC 11601 HCPCS outpatient 471 353.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 419.19 89 999999999 367.38 447.45 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11602_3 CDM 360 RC 11602 HCPCS outpatient 502 376.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 451.8 999999999 391.56 476.9 case rate "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11602_3 CDM 360 RC 11602 HCPCS outpatient 502 376.5 AETNA MCR ADV AETNA MCR ADV 391.56 78 999999999 391.56 476.9 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11602_3 CDM 360 RC 11602 HCPCS outpatient 502 376.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 439.6 87.57 999999999 391.56 476.9 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11602_3 CDM 360 RC 11602 HCPCS outpatient 502 376.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 427.05 85.07 999999999 391.56 476.9 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11602_3 CDM 360 RC 11602 HCPCS outpatient 502 376.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 427.05 85.07 999999999 391.56 476.9 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11602_3 CDM 360 RC 11602 HCPCS outpatient 502 376.5 MOLINA MCAID MOLINA MCAID 418.67 83.4 999999999 391.56 476.9 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11602_3 CDM 360 RC 11602 HCPCS outpatient 502 376.5 MOLINA MCR ADV MOLINA MCR ADV 446.78 89 999999999 391.56 476.9 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11602_3 CDM 360 RC 11602 HCPCS outpatient 502 376.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 446.78 89 999999999 391.56 476.9 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11602_3 CDM 360 RC 11602 HCPCS outpatient 502 376.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 446.78 89 999999999 391.56 476.9 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11602_3 CDM 360 RC 11602 HCPCS outpatient 502 376.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 451.8 90 999999999 391.56 476.9 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11602_3 CDM 360 RC 11602 HCPCS outpatient 502 376.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 476.9 95 999999999 391.56 476.9 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11602_3 CDM 360 RC 11602 HCPCS outpatient 502 376.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 476.9 95 999999999 391.56 476.9 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11602_3 CDM 360 RC 11602 HCPCS outpatient 502 376.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 446.78 89 999999999 391.56 476.9 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11602_3 CDM 360 RC 11602 HCPCS outpatient 502 376.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 441.76 88 999999999 391.56 476.9 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11602_3 CDM 360 RC 11602 HCPCS outpatient 502 376.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 446.78 89 999999999 391.56 476.9 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM" 11604_3 CDM 360 RC 11604 HCPCS outpatient 634 475.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 570.6 999999999 494.52 602.3 case rate "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM" 11604_3 CDM 360 RC 11604 HCPCS outpatient 634 475.5 AETNA MCR ADV AETNA MCR ADV 494.52 78 999999999 494.52 602.3 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM" 11604_3 CDM 360 RC 11604 HCPCS outpatient 634 475.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 555.19 87.57 999999999 494.52 602.3 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM" 11604_3 CDM 360 RC 11604 HCPCS outpatient 634 475.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 539.34 85.07 999999999 494.52 602.3 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM" 11604_3 CDM 360 RC 11604 HCPCS outpatient 634 475.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 539.34 85.07 999999999 494.52 602.3 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM" 11604_3 CDM 360 RC 11604 HCPCS outpatient 634 475.5 MOLINA MCAID MOLINA MCAID 528.76 83.4 999999999 494.52 602.3 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM" 11604_3 CDM 360 RC 11604 HCPCS outpatient 634 475.5 MOLINA MCR ADV MOLINA MCR ADV 564.26 89 999999999 494.52 602.3 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM" 11604_3 CDM 360 RC 11604 HCPCS outpatient 634 475.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 564.26 89 999999999 494.52 602.3 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM" 11604_3 CDM 360 RC 11604 HCPCS outpatient 634 475.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 564.26 89 999999999 494.52 602.3 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM" 11604_3 CDM 360 RC 11604 HCPCS outpatient 634 475.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 570.6 90 999999999 494.52 602.3 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM" 11604_3 CDM 360 RC 11604 HCPCS outpatient 634 475.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 602.3 95 999999999 494.52 602.3 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM" 11604_3 CDM 360 RC 11604 HCPCS outpatient 634 475.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 602.3 95 999999999 494.52 602.3 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM" 11604_3 CDM 360 RC 11604 HCPCS outpatient 634 475.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 564.26 89 999999999 494.52 602.3 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM" 11604_3 CDM 360 RC 11604 HCPCS outpatient 634 475.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 557.92 88 999999999 494.52 602.3 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM" 11604_3 CDM 360 RC 11604 HCPCS outpatient 634 475.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 564.26 89 999999999 494.52 602.3 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER OVER 4.0 CM" 11606_3 CDM 360 RC 11606 HCPCS outpatient 910 682.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 819 999999999 709.8 864.5 case rate "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER OVER 4.0 CM" 11606_3 CDM 360 RC 11606 HCPCS outpatient 910 682.5 AETNA MCR ADV AETNA MCR ADV 709.8 78 999999999 709.8 864.5 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER OVER 4.0 CM" 11606_3 CDM 360 RC 11606 HCPCS outpatient 910 682.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 796.89 87.57 999999999 709.8 864.5 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER OVER 4.0 CM" 11606_3 CDM 360 RC 11606 HCPCS outpatient 910 682.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 774.14 85.07 999999999 709.8 864.5 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER OVER 4.0 CM" 11606_3 CDM 360 RC 11606 HCPCS outpatient 910 682.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 774.14 85.07 999999999 709.8 864.5 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER OVER 4.0 CM" 11606_3 CDM 360 RC 11606 HCPCS outpatient 910 682.5 MOLINA MCAID MOLINA MCAID 758.94 83.4 999999999 709.8 864.5 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER OVER 4.0 CM" 11606_3 CDM 360 RC 11606 HCPCS outpatient 910 682.5 MOLINA MCR ADV MOLINA MCR ADV 809.9 89 999999999 709.8 864.5 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER OVER 4.0 CM" 11606_3 CDM 360 RC 11606 HCPCS outpatient 910 682.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 809.9 89 999999999 709.8 864.5 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER OVER 4.0 CM" 11606_3 CDM 360 RC 11606 HCPCS outpatient 910 682.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 809.9 89 999999999 709.8 864.5 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER OVER 4.0 CM" 11606_3 CDM 360 RC 11606 HCPCS outpatient 910 682.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 819 90 999999999 709.8 864.5 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER OVER 4.0 CM" 11606_3 CDM 360 RC 11606 HCPCS outpatient 910 682.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 864.5 95 999999999 709.8 864.5 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER OVER 4.0 CM" 11606_3 CDM 360 RC 11606 HCPCS outpatient 910 682.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 864.5 95 999999999 709.8 864.5 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER OVER 4.0 CM" 11606_3 CDM 360 RC 11606 HCPCS outpatient 910 682.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 809.9 89 999999999 709.8 864.5 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER OVER 4.0 CM" 11606_3 CDM 360 RC 11606 HCPCS outpatient 910 682.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 800.8 88 999999999 709.8 864.5 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER OVER 4.0 CM" 11606_3 CDM 360 RC 11606 HCPCS outpatient 910 682.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 809.9 89 999999999 709.8 864.5 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS" 11620_3 CDM 360 RC 11620 HCPCS outpatient 410 307.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 369 999999999 319.8 389.5 case rate "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS" 11620_3 CDM 360 RC 11620 HCPCS outpatient 410 307.5 AETNA MCR ADV AETNA MCR ADV 319.8 78 999999999 319.8 389.5 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS" 11620_3 CDM 360 RC 11620 HCPCS outpatient 410 307.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 359.04 87.57 999999999 319.8 389.5 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS" 11620_3 CDM 360 RC 11620 HCPCS outpatient 410 307.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 348.79 85.07 999999999 319.8 389.5 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS" 11620_3 CDM 360 RC 11620 HCPCS outpatient 410 307.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 348.79 85.07 999999999 319.8 389.5 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS" 11620_3 CDM 360 RC 11620 HCPCS outpatient 410 307.5 MOLINA MCAID MOLINA MCAID 341.94 83.4 999999999 319.8 389.5 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS" 11620_3 CDM 360 RC 11620 HCPCS outpatient 410 307.5 MOLINA MCR ADV MOLINA MCR ADV 364.9 89 999999999 319.8 389.5 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS" 11620_3 CDM 360 RC 11620 HCPCS outpatient 410 307.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 364.9 89 999999999 319.8 389.5 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS" 11620_3 CDM 360 RC 11620 HCPCS outpatient 410 307.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 364.9 89 999999999 319.8 389.5 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS" 11620_3 CDM 360 RC 11620 HCPCS outpatient 410 307.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 369 90 999999999 319.8 389.5 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS" 11620_3 CDM 360 RC 11620 HCPCS outpatient 410 307.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 389.5 95 999999999 319.8 389.5 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS" 11620_3 CDM 360 RC 11620 HCPCS outpatient 410 307.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 389.5 95 999999999 319.8 389.5 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS" 11620_3 CDM 360 RC 11620 HCPCS outpatient 410 307.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 364.9 89 999999999 319.8 389.5 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS" 11620_3 CDM 360 RC 11620 HCPCS outpatient 410 307.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 360.8 88 999999999 319.8 389.5 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS" 11620_3 CDM 360 RC 11620 HCPCS outpatient 410 307.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 364.9 89 999999999 319.8 389.5 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM" 11621_3 CDM 360 RC 11621 HCPCS outpatient 472 354 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 424.8 999999999 368.16 448.4 case rate "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM" 11621_3 CDM 360 RC 11621 HCPCS outpatient 472 354 AETNA MCR ADV AETNA MCR ADV 368.16 78 999999999 368.16 448.4 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM" 11621_3 CDM 360 RC 11621 HCPCS outpatient 472 354 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 413.33 87.57 999999999 368.16 448.4 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM" 11621_3 CDM 360 RC 11621 HCPCS outpatient 472 354 COORDINATED CARE MCAID COORDINATED CARE MCAID 401.53 85.07 999999999 368.16 448.4 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM" 11621_3 CDM 360 RC 11621 HCPCS outpatient 472 354 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 401.53 85.07 999999999 368.16 448.4 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM" 11621_3 CDM 360 RC 11621 HCPCS outpatient 472 354 MOLINA MCAID MOLINA MCAID 393.65 83.4 999999999 368.16 448.4 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM" 11621_3 CDM 360 RC 11621 HCPCS outpatient 472 354 MOLINA MCR ADV MOLINA MCR ADV 420.08 89 999999999 368.16 448.4 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM" 11621_3 CDM 360 RC 11621 HCPCS outpatient 472 354 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 420.08 89 999999999 368.16 448.4 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM" 11621_3 CDM 360 RC 11621 HCPCS outpatient 472 354 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 420.08 89 999999999 368.16 448.4 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM" 11621_3 CDM 360 RC 11621 HCPCS outpatient 472 354 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 424.8 90 999999999 368.16 448.4 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM" 11621_3 CDM 360 RC 11621 HCPCS outpatient 472 354 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 448.4 95 999999999 368.16 448.4 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM" 11621_3 CDM 360 RC 11621 HCPCS outpatient 472 354 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 448.4 95 999999999 368.16 448.4 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM" 11621_3 CDM 360 RC 11621 HCPCS outpatient 472 354 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 420.08 89 999999999 368.16 448.4 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM" 11621_3 CDM 360 RC 11621 HCPCS outpatient 472 354 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 415.36 88 999999999 368.16 448.4 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM" 11621_3 CDM 360 RC 11621 HCPCS outpatient 472 354 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 420.08 89 999999999 368.16 448.4 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM" 11623_3 CDM 360 RC 11623 HCPCS outpatient 606 454.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 545.4 999999999 472.68 575.7 case rate "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM" 11623_3 CDM 360 RC 11623 HCPCS outpatient 606 454.5 AETNA MCR ADV AETNA MCR ADV 472.68 78 999999999 472.68 575.7 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM" 11623_3 CDM 360 RC 11623 HCPCS outpatient 606 454.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 530.67 87.57 999999999 472.68 575.7 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM" 11623_3 CDM 360 RC 11623 HCPCS outpatient 606 454.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 515.52 85.07 999999999 472.68 575.7 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM" 11623_3 CDM 360 RC 11623 HCPCS outpatient 606 454.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 515.52 85.07 999999999 472.68 575.7 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM" 11623_3 CDM 360 RC 11623 HCPCS outpatient 606 454.5 MOLINA MCAID MOLINA MCAID 505.4 83.4 999999999 472.68 575.7 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM" 11623_3 CDM 360 RC 11623 HCPCS outpatient 606 454.5 MOLINA MCR ADV MOLINA MCR ADV 539.34 89 999999999 472.68 575.7 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM" 11623_3 CDM 360 RC 11623 HCPCS outpatient 606 454.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 539.34 89 999999999 472.68 575.7 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM" 11623_3 CDM 360 RC 11623 HCPCS outpatient 606 454.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 539.34 89 999999999 472.68 575.7 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM" 11623_3 CDM 360 RC 11623 HCPCS outpatient 606 454.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 545.4 90 999999999 472.68 575.7 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM" 11623_3 CDM 360 RC 11623 HCPCS outpatient 606 454.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 575.7 95 999999999 472.68 575.7 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM" 11623_3 CDM 360 RC 11623 HCPCS outpatient 606 454.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 575.7 95 999999999 472.68 575.7 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM" 11623_3 CDM 360 RC 11623 HCPCS outpatient 606 454.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 539.34 89 999999999 472.68 575.7 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM" 11623_3 CDM 360 RC 11623 HCPCS outpatient 606 454.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 533.28 88 999999999 472.68 575.7 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM" 11623_3 CDM 360 RC 11623 HCPCS outpatient 606 454.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 539.34 89 999999999 472.68 575.7 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM" 11624_3 CDM 360 RC 11624 HCPCS outpatient 688 516 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 619.2 999999999 536.64 653.6 case rate "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM" 11624_3 CDM 360 RC 11624 HCPCS outpatient 688 516 AETNA MCR ADV AETNA MCR ADV 536.64 78 999999999 536.64 653.6 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM" 11624_3 CDM 360 RC 11624 HCPCS outpatient 688 516 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 602.48 87.57 999999999 536.64 653.6 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM" 11624_3 CDM 360 RC 11624 HCPCS outpatient 688 516 COORDINATED CARE MCAID COORDINATED CARE MCAID 585.28 85.07 999999999 536.64 653.6 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM" 11624_3 CDM 360 RC 11624 HCPCS outpatient 688 516 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 585.28 85.07 999999999 536.64 653.6 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM" 11624_3 CDM 360 RC 11624 HCPCS outpatient 688 516 MOLINA MCAID MOLINA MCAID 573.79 83.4 999999999 536.64 653.6 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM" 11624_3 CDM 360 RC 11624 HCPCS outpatient 688 516 MOLINA MCR ADV MOLINA MCR ADV 612.32 89 999999999 536.64 653.6 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM" 11624_3 CDM 360 RC 11624 HCPCS outpatient 688 516 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 612.32 89 999999999 536.64 653.6 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM" 11624_3 CDM 360 RC 11624 HCPCS outpatient 688 516 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 612.32 89 999999999 536.64 653.6 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM" 11624_3 CDM 360 RC 11624 HCPCS outpatient 688 516 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 619.2 90 999999999 536.64 653.6 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM" 11624_3 CDM 360 RC 11624 HCPCS outpatient 688 516 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 653.6 95 999999999 536.64 653.6 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM" 11624_3 CDM 360 RC 11624 HCPCS outpatient 688 516 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 653.6 95 999999999 536.64 653.6 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM" 11624_3 CDM 360 RC 11624 HCPCS outpatient 688 516 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 612.32 89 999999999 536.64 653.6 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM" 11624_3 CDM 360 RC 11624 HCPCS outpatient 688 516 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 605.44 88 999999999 536.64 653.6 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM" 11624_3 CDM 360 RC 11624 HCPCS outpatient 688 516 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 612.32 89 999999999 536.64 653.6 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.5 CM OR LESS" 11640_3 CDM 360 RC 11640 HCPCS outpatient 420 315 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 378 999999999 327.6 399 case rate "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.5 CM OR LESS" 11640_3 CDM 360 RC 11640 HCPCS outpatient 420 315 AETNA MCR ADV AETNA MCR ADV 327.6 78 999999999 327.6 399 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.5 CM OR LESS" 11640_3 CDM 360 RC 11640 HCPCS outpatient 420 315 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 367.79 87.57 999999999 327.6 399 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.5 CM OR LESS" 11640_3 CDM 360 RC 11640 HCPCS outpatient 420 315 COORDINATED CARE MCAID COORDINATED CARE MCAID 357.29 85.07 999999999 327.6 399 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.5 CM OR LESS" 11640_3 CDM 360 RC 11640 HCPCS outpatient 420 315 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 357.29 85.07 999999999 327.6 399 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.5 CM OR LESS" 11640_3 CDM 360 RC 11640 HCPCS outpatient 420 315 MOLINA MCAID MOLINA MCAID 350.28 83.4 999999999 327.6 399 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.5 CM OR LESS" 11640_3 CDM 360 RC 11640 HCPCS outpatient 420 315 MOLINA MCR ADV MOLINA MCR ADV 373.8 89 999999999 327.6 399 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.5 CM OR LESS" 11640_3 CDM 360 RC 11640 HCPCS outpatient 420 315 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 373.8 89 999999999 327.6 399 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.5 CM OR LESS" 11640_3 CDM 360 RC 11640 HCPCS outpatient 420 315 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 373.8 89 999999999 327.6 399 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.5 CM OR LESS" 11640_3 CDM 360 RC 11640 HCPCS outpatient 420 315 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 378 90 999999999 327.6 399 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.5 CM OR LESS" 11640_3 CDM 360 RC 11640 HCPCS outpatient 420 315 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 399 95 999999999 327.6 399 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.5 CM OR LESS" 11640_3 CDM 360 RC 11640 HCPCS outpatient 420 315 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 399 95 999999999 327.6 399 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.5 CM OR LESS" 11640_3 CDM 360 RC 11640 HCPCS outpatient 420 315 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 373.8 89 999999999 327.6 399 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.5 CM OR LESS" 11640_3 CDM 360 RC 11640 HCPCS outpatient 420 315 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 369.6 88 999999999 327.6 399 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.5 CM OR LESS" 11640_3 CDM 360 RC 11640 HCPCS outpatient 420 315 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 373.8 89 999999999 327.6 399 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11641_3 CDM 360 RC 11641 HCPCS outpatient 486 364.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 461.7 95 999999999 379.08 461.7 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11641_3 CDM 360 RC 11641 HCPCS outpatient 486 364.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 432.54 89 999999999 379.08 461.7 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11641_3 CDM 360 RC 11641 HCPCS outpatient 486 364.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 427.68 88 999999999 379.08 461.7 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11641_3 CDM 360 RC 11641 HCPCS outpatient 486 364.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 432.54 89 999999999 379.08 461.7 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11641_3 CDM 360 RC 11641 HCPCS outpatient 486 364.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 437.4 999999999 379.08 461.7 case rate "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11641_3 CDM 360 RC 11641 HCPCS outpatient 486 364.5 AETNA MCR ADV AETNA MCR ADV 379.08 78 999999999 379.08 461.7 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11641_3 CDM 360 RC 11641 HCPCS outpatient 486 364.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 425.59 87.57 999999999 379.08 461.7 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11641_3 CDM 360 RC 11641 HCPCS outpatient 486 364.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 413.44 85.07 999999999 379.08 461.7 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11641_3 CDM 360 RC 11641 HCPCS outpatient 486 364.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 413.44 85.07 999999999 379.08 461.7 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11641_3 CDM 360 RC 11641 HCPCS outpatient 486 364.5 MOLINA MCAID MOLINA MCAID 405.32 83.4 999999999 379.08 461.7 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11641_3 CDM 360 RC 11641 HCPCS outpatient 486 364.5 MOLINA MCR ADV MOLINA MCR ADV 432.54 89 999999999 379.08 461.7 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11641_3 CDM 360 RC 11641 HCPCS outpatient 486 364.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 432.54 89 999999999 379.08 461.7 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11641_3 CDM 360 RC 11641 HCPCS outpatient 486 364.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 432.54 89 999999999 379.08 461.7 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11641_3 CDM 360 RC 11641 HCPCS outpatient 486 364.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 437.4 90 999999999 379.08 461.7 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.6 TO 1.0 CM" 11641_3 CDM 360 RC 11641 HCPCS outpatient 486 364.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 461.7 95 999999999 379.08 461.7 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11642_3 CDM 360 RC 11642 HCPCS outpatient 550 412.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 495 999999999 429 522.5 case rate "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11642_3 CDM 360 RC 11642 HCPCS outpatient 550 412.5 AETNA MCR ADV AETNA MCR ADV 429 78 999999999 429 522.5 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11642_3 CDM 360 RC 11642 HCPCS outpatient 550 412.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 481.64 87.57 999999999 429 522.5 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11642_3 CDM 360 RC 11642 HCPCS outpatient 550 412.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 467.89 85.07 999999999 429 522.5 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11642_3 CDM 360 RC 11642 HCPCS outpatient 550 412.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 467.89 85.07 999999999 429 522.5 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11642_3 CDM 360 RC 11642 HCPCS outpatient 550 412.5 MOLINA MCAID MOLINA MCAID 458.7 83.4 999999999 429 522.5 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11642_3 CDM 360 RC 11642 HCPCS outpatient 550 412.5 MOLINA MCR ADV MOLINA MCR ADV 489.5 89 999999999 429 522.5 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11642_3 CDM 360 RC 11642 HCPCS outpatient 550 412.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 489.5 89 999999999 429 522.5 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11642_3 CDM 360 RC 11642 HCPCS outpatient 550 412.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 489.5 89 999999999 429 522.5 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11642_3 CDM 360 RC 11642 HCPCS outpatient 550 412.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 495 90 999999999 429 522.5 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11642_3 CDM 360 RC 11642 HCPCS outpatient 550 412.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 522.5 95 999999999 429 522.5 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11642_3 CDM 360 RC 11642 HCPCS outpatient 550 412.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 522.5 95 999999999 429 522.5 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11642_3 CDM 360 RC 11642 HCPCS outpatient 550 412.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 489.5 89 999999999 429 522.5 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11642_3 CDM 360 RC 11642 HCPCS outpatient 550 412.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 484 88 999999999 429 522.5 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 1.1 TO 2.0 CM" 11642_3 CDM 360 RC 11642 HCPCS outpatient 550 412.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 489.5 89 999999999 429 522.5 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 2.1 TO 3.0 CM" 11643_3 CDM 360 RC 11643 HCPCS outpatient 644 483 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 579.6 999999999 502.32 611.8 case rate "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 2.1 TO 3.0 CM" 11643_3 CDM 360 RC 11643 HCPCS outpatient 644 483 AETNA MCR ADV AETNA MCR ADV 502.32 78 999999999 502.32 611.8 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 2.1 TO 3.0 CM" 11643_3 CDM 360 RC 11643 HCPCS outpatient 644 483 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 563.95 87.57 999999999 502.32 611.8 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 2.1 TO 3.0 CM" 11643_3 CDM 360 RC 11643 HCPCS outpatient 644 483 COORDINATED CARE MCAID COORDINATED CARE MCAID 547.85 85.07 999999999 502.32 611.8 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 2.1 TO 3.0 CM" 11643_3 CDM 360 RC 11643 HCPCS outpatient 644 483 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 547.85 85.07 999999999 502.32 611.8 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 2.1 TO 3.0 CM" 11643_3 CDM 360 RC 11643 HCPCS outpatient 644 483 MOLINA MCAID MOLINA MCAID 537.1 83.4 999999999 502.32 611.8 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 2.1 TO 3.0 CM" 11643_3 CDM 360 RC 11643 HCPCS outpatient 644 483 MOLINA MCR ADV MOLINA MCR ADV 573.16 89 999999999 502.32 611.8 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 2.1 TO 3.0 CM" 11643_3 CDM 360 RC 11643 HCPCS outpatient 644 483 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 573.16 89 999999999 502.32 611.8 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 2.1 TO 3.0 CM" 11643_3 CDM 360 RC 11643 HCPCS outpatient 644 483 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 573.16 89 999999999 502.32 611.8 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 2.1 TO 3.0 CM" 11643_3 CDM 360 RC 11643 HCPCS outpatient 644 483 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 579.6 90 999999999 502.32 611.8 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 2.1 TO 3.0 CM" 11643_3 CDM 360 RC 11643 HCPCS outpatient 644 483 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 611.8 95 999999999 502.32 611.8 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 2.1 TO 3.0 CM" 11643_3 CDM 360 RC 11643 HCPCS outpatient 644 483 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 611.8 95 999999999 502.32 611.8 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 2.1 TO 3.0 CM" 11643_3 CDM 360 RC 11643 HCPCS outpatient 644 483 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 573.16 89 999999999 502.32 611.8 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 2.1 TO 3.0 CM" 11643_3 CDM 360 RC 11643 HCPCS outpatient 644 483 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 566.72 88 999999999 502.32 611.8 percent of total billed charges "EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 2.1 TO 3.0 CM" 11643_3 CDM 360 RC 11643 HCPCS outpatient 644 483 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 573.16 89 999999999 502.32 611.8 percent of total billed charges "TRIMMING OF NONDYSTROPHIC NAILS, ANY NUMBER" 11719_3 CDM 360 RC 11719 HCPCS outpatient 29 21.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 26.1 999999999 22.62 27.55 case rate "TRIMMING OF NONDYSTROPHIC NAILS, ANY NUMBER" 11719_3 CDM 360 RC 11719 HCPCS outpatient 29 21.75 AETNA MCR ADV AETNA MCR ADV 22.62 78 999999999 22.62 27.55 percent of total billed charges "TRIMMING OF NONDYSTROPHIC NAILS, ANY NUMBER" 11719_3 CDM 360 RC 11719 HCPCS outpatient 29 21.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 25.4 87.57 999999999 22.62 27.55 percent of total billed charges "TRIMMING OF NONDYSTROPHIC NAILS, ANY NUMBER" 11719_3 CDM 360 RC 11719 HCPCS outpatient 29 21.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 24.67 85.07 999999999 22.62 27.55 percent of total billed charges "TRIMMING OF NONDYSTROPHIC NAILS, ANY NUMBER" 11719_3 CDM 360 RC 11719 HCPCS outpatient 29 21.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 24.67 85.07 999999999 22.62 27.55 percent of total billed charges "TRIMMING OF NONDYSTROPHIC NAILS, ANY NUMBER" 11719_3 CDM 360 RC 11719 HCPCS outpatient 29 21.75 MOLINA MCAID MOLINA MCAID 24.19 83.4 999999999 22.62 27.55 percent of total billed charges "TRIMMING OF NONDYSTROPHIC NAILS, ANY NUMBER" 11719_3 CDM 360 RC 11719 HCPCS outpatient 29 21.75 MOLINA MCR ADV MOLINA MCR ADV 25.81 89 999999999 22.62 27.55 percent of total billed charges "TRIMMING OF NONDYSTROPHIC NAILS, ANY NUMBER" 11719_3 CDM 360 RC 11719 HCPCS outpatient 29 21.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 25.81 89 999999999 22.62 27.55 percent of total billed charges "TRIMMING OF NONDYSTROPHIC NAILS, ANY NUMBER" 11719_3 CDM 360 RC 11719 HCPCS outpatient 29 21.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 25.81 89 999999999 22.62 27.55 percent of total billed charges "TRIMMING OF NONDYSTROPHIC NAILS, ANY NUMBER" 11719_3 CDM 360 RC 11719 HCPCS outpatient 29 21.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 26.1 90 999999999 22.62 27.55 percent of total billed charges "TRIMMING OF NONDYSTROPHIC NAILS, ANY NUMBER" 11719_3 CDM 360 RC 11719 HCPCS outpatient 29 21.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 27.55 95 999999999 22.62 27.55 percent of total billed charges "TRIMMING OF NONDYSTROPHIC NAILS, ANY NUMBER" 11719_3 CDM 360 RC 11719 HCPCS outpatient 29 21.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 27.55 95 999999999 22.62 27.55 percent of total billed charges "TRIMMING OF NONDYSTROPHIC NAILS, ANY NUMBER" 11719_3 CDM 360 RC 11719 HCPCS outpatient 29 21.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 25.81 89 999999999 22.62 27.55 percent of total billed charges "TRIMMING OF NONDYSTROPHIC NAILS, ANY NUMBER" 11719_3 CDM 360 RC 11719 HCPCS outpatient 29 21.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 25.52 88 999999999 22.62 27.55 percent of total billed charges "TRIMMING OF NONDYSTROPHIC NAILS, ANY NUMBER" 11719_3 CDM 360 RC 11719 HCPCS outpatient 29 21.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 25.81 89 999999999 22.62 27.55 percent of total billed charges DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); 1 TO 5 11720_3 CDM 360 RC 11720 HCPCS outpatient 66 49.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 59.4 999999999 51.48 62.7 case rate DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); 1 TO 5 11720_3 CDM 360 RC 11720 HCPCS outpatient 66 49.5 AETNA MCR ADV AETNA MCR ADV 51.48 78 999999999 51.48 62.7 percent of total billed charges DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); 1 TO 5 11720_3 CDM 360 RC 11720 HCPCS outpatient 66 49.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 57.8 87.57 999999999 51.48 62.7 percent of total billed charges DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); 1 TO 5 11720_3 CDM 360 RC 11720 HCPCS outpatient 66 49.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 56.15 85.07 999999999 51.48 62.7 percent of total billed charges DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); 1 TO 5 11720_3 CDM 360 RC 11720 HCPCS outpatient 66 49.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 56.15 85.07 999999999 51.48 62.7 percent of total billed charges DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); 1 TO 5 11720_3 CDM 360 RC 11720 HCPCS outpatient 66 49.5 MOLINA MCAID MOLINA MCAID 55.04 83.4 999999999 51.48 62.7 percent of total billed charges DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); 1 TO 5 11720_3 CDM 360 RC 11720 HCPCS outpatient 66 49.5 MOLINA MCR ADV MOLINA MCR ADV 58.74 89 999999999 51.48 62.7 percent of total billed charges DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); 1 TO 5 11720_3 CDM 360 RC 11720 HCPCS outpatient 66 49.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 58.74 89 999999999 51.48 62.7 percent of total billed charges DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); 1 TO 5 11720_3 CDM 360 RC 11720 HCPCS outpatient 66 49.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 58.74 89 999999999 51.48 62.7 percent of total billed charges DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); 1 TO 5 11720_3 CDM 360 RC 11720 HCPCS outpatient 66 49.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 59.4 90 999999999 51.48 62.7 percent of total billed charges DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); 1 TO 5 11720_3 CDM 360 RC 11720 HCPCS outpatient 66 49.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 62.7 95 999999999 51.48 62.7 percent of total billed charges DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); 1 TO 5 11720_3 CDM 360 RC 11720 HCPCS outpatient 66 49.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 62.7 95 999999999 51.48 62.7 percent of total billed charges DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); 1 TO 5 11720_3 CDM 360 RC 11720 HCPCS outpatient 66 49.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 58.74 89 999999999 51.48 62.7 percent of total billed charges DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); 1 TO 5 11720_3 CDM 360 RC 11720 HCPCS outpatient 66 49.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 58.08 88 999999999 51.48 62.7 percent of total billed charges DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); 1 TO 5 11720_3 CDM 360 RC 11720 HCPCS outpatient 66 49.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 58.74 89 999999999 51.48 62.7 percent of total billed charges DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); 6 OR MORE 11721_3 CDM 360 RC 11721 HCPCS outpatient 90 67.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 81 999999999 70.2 85.5 case rate DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); 6 OR MORE 11721_3 CDM 360 RC 11721 HCPCS outpatient 90 67.5 AETNA MCR ADV AETNA MCR ADV 70.2 78 999999999 70.2 85.5 percent of total billed charges DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); 6 OR MORE 11721_3 CDM 360 RC 11721 HCPCS outpatient 90 67.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 78.81 87.57 999999999 70.2 85.5 percent of total billed charges DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); 6 OR MORE 11721_3 CDM 360 RC 11721 HCPCS outpatient 90 67.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 76.56 85.07 999999999 70.2 85.5 percent of total billed charges DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); 6 OR MORE 11721_3 CDM 360 RC 11721 HCPCS outpatient 90 67.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 76.56 85.07 999999999 70.2 85.5 percent of total billed charges DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); 6 OR MORE 11721_3 CDM 360 RC 11721 HCPCS outpatient 90 67.5 MOLINA MCAID MOLINA MCAID 75.06 83.4 999999999 70.2 85.5 percent of total billed charges DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); 6 OR MORE 11721_3 CDM 360 RC 11721 HCPCS outpatient 90 67.5 MOLINA MCR ADV MOLINA MCR ADV 80.1 89 999999999 70.2 85.5 percent of total billed charges DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); 6 OR MORE 11721_3 CDM 360 RC 11721 HCPCS outpatient 90 67.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 80.1 89 999999999 70.2 85.5 percent of total billed charges DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); 6 OR MORE 11721_3 CDM 360 RC 11721 HCPCS outpatient 90 67.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 80.1 89 999999999 70.2 85.5 percent of total billed charges DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); 6 OR MORE 11721_3 CDM 360 RC 11721 HCPCS outpatient 90 67.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 81 90 999999999 70.2 85.5 percent of total billed charges DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); 6 OR MORE 11721_3 CDM 360 RC 11721 HCPCS outpatient 90 67.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 85.5 95 999999999 70.2 85.5 percent of total billed charges DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); 6 OR MORE 11721_3 CDM 360 RC 11721 HCPCS outpatient 90 67.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 85.5 95 999999999 70.2 85.5 percent of total billed charges DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); 6 OR MORE 11721_3 CDM 360 RC 11721 HCPCS outpatient 90 67.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 80.1 89 999999999 70.2 85.5 percent of total billed charges DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); 6 OR MORE 11721_3 CDM 360 RC 11721 HCPCS outpatient 90 67.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 79.2 88 999999999 70.2 85.5 percent of total billed charges DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); 6 OR MORE 11721_3 CDM 360 RC 11721 HCPCS outpatient 90 67.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 80.1 89 999999999 70.2 85.5 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_1 CDM 360 RC 11730 HCPCS outpatient 161.22 120.92 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 145.1 999999999 125.75 153.16 case rate "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_1 CDM 360 RC 11730 HCPCS outpatient 161.22 120.92 AETNA MCR ADV AETNA MCR ADV 125.75 78 999999999 125.75 153.16 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_1 CDM 360 RC 11730 HCPCS outpatient 161.22 120.92 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 141.18 87.57 999999999 125.75 153.16 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_1 CDM 360 RC 11730 HCPCS outpatient 161.22 120.92 COORDINATED CARE MCAID COORDINATED CARE MCAID 137.15 85.07 999999999 125.75 153.16 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_1 CDM 360 RC 11730 HCPCS outpatient 161.22 120.92 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 137.15 85.07 999999999 125.75 153.16 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_1 CDM 360 RC 11730 HCPCS outpatient 161.22 120.92 MOLINA MCAID MOLINA MCAID 134.46 83.4 999999999 125.75 153.16 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_1 CDM 360 RC 11730 HCPCS outpatient 161.22 120.92 MOLINA MCR ADV MOLINA MCR ADV 143.49 89 999999999 125.75 153.16 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_1 CDM 360 RC 11730 HCPCS outpatient 161.22 120.92 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 143.49 89 999999999 125.75 153.16 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_1 CDM 360 RC 11730 HCPCS outpatient 161.22 120.92 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 143.49 89 999999999 125.75 153.16 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_1 CDM 360 RC 11730 HCPCS outpatient 161.22 120.92 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 145.1 90 999999999 125.75 153.16 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_1 CDM 360 RC 11730 HCPCS outpatient 161.22 120.92 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 153.16 95 999999999 125.75 153.16 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_1 CDM 360 RC 11730 HCPCS outpatient 161.22 120.92 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 153.16 95 999999999 125.75 153.16 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_1 CDM 360 RC 11730 HCPCS outpatient 161.22 120.92 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 143.49 89 999999999 125.75 153.16 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_1 CDM 360 RC 11730 HCPCS outpatient 161.22 120.92 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 141.87 88 999999999 125.75 153.16 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_1 CDM 360 RC 11730 HCPCS outpatient 161.22 120.92 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 143.49 89 999999999 125.75 153.16 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_2 CDM 360 RC 11730 HCPCS outpatient 161.22 120.92 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 145.1 999999999 125.75 153.16 case rate "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_2 CDM 360 RC 11730 HCPCS outpatient 161.22 120.92 AETNA MCR ADV AETNA MCR ADV 125.75 78 999999999 125.75 153.16 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_2 CDM 360 RC 11730 HCPCS outpatient 161.22 120.92 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 141.18 87.57 999999999 125.75 153.16 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_2 CDM 360 RC 11730 HCPCS outpatient 161.22 120.92 COORDINATED CARE MCAID COORDINATED CARE MCAID 137.15 85.07 999999999 125.75 153.16 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_2 CDM 360 RC 11730 HCPCS outpatient 161.22 120.92 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 137.15 85.07 999999999 125.75 153.16 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_2 CDM 360 RC 11730 HCPCS outpatient 161.22 120.92 MOLINA MCAID MOLINA MCAID 134.46 83.4 999999999 125.75 153.16 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_2 CDM 360 RC 11730 HCPCS outpatient 161.22 120.92 MOLINA MCR ADV MOLINA MCR ADV 143.49 89 999999999 125.75 153.16 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_2 CDM 360 RC 11730 HCPCS outpatient 161.22 120.92 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 143.49 89 999999999 125.75 153.16 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_2 CDM 360 RC 11730 HCPCS outpatient 161.22 120.92 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 143.49 89 999999999 125.75 153.16 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_2 CDM 360 RC 11730 HCPCS outpatient 161.22 120.92 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 145.1 90 999999999 125.75 153.16 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_2 CDM 360 RC 11730 HCPCS outpatient 161.22 120.92 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 153.16 95 999999999 125.75 153.16 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_2 CDM 360 RC 11730 HCPCS outpatient 161.22 120.92 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 153.16 95 999999999 125.75 153.16 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_2 CDM 360 RC 11730 HCPCS outpatient 161.22 120.92 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 143.49 89 999999999 125.75 153.16 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_2 CDM 360 RC 11730 HCPCS outpatient 161.22 120.92 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 141.87 88 999999999 125.75 153.16 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_2 CDM 360 RC 11730 HCPCS outpatient 161.22 120.92 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 143.49 89 999999999 125.75 153.16 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_3 CDM 360 RC 11730 HCPCS outpatient 238 178.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 214.2 999999999 185.64 226.1 case rate "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_3 CDM 360 RC 11730 HCPCS outpatient 238 178.5 AETNA MCR ADV AETNA MCR ADV 185.64 78 999999999 185.64 226.1 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_3 CDM 360 RC 11730 HCPCS outpatient 238 178.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 208.42 87.57 999999999 185.64 226.1 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_3 CDM 360 RC 11730 HCPCS outpatient 238 178.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 202.47 85.07 999999999 185.64 226.1 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_3 CDM 360 RC 11730 HCPCS outpatient 238 178.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 202.47 85.07 999999999 185.64 226.1 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_3 CDM 360 RC 11730 HCPCS outpatient 238 178.5 MOLINA MCAID MOLINA MCAID 198.49 83.4 999999999 185.64 226.1 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_3 CDM 360 RC 11730 HCPCS outpatient 238 178.5 MOLINA MCR ADV MOLINA MCR ADV 211.82 89 999999999 185.64 226.1 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_3 CDM 360 RC 11730 HCPCS outpatient 238 178.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 211.82 89 999999999 185.64 226.1 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_3 CDM 360 RC 11730 HCPCS outpatient 238 178.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 211.82 89 999999999 185.64 226.1 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_3 CDM 360 RC 11730 HCPCS outpatient 238 178.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 214.2 90 999999999 185.64 226.1 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_3 CDM 360 RC 11730 HCPCS outpatient 238 178.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 226.1 95 999999999 185.64 226.1 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_3 CDM 360 RC 11730 HCPCS outpatient 238 178.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 226.1 95 999999999 185.64 226.1 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_3 CDM 360 RC 11730 HCPCS outpatient 238 178.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 211.82 89 999999999 185.64 226.1 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_3 CDM 360 RC 11730 HCPCS outpatient 238 178.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 209.44 88 999999999 185.64 226.1 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 11730_3 CDM 360 RC 11730 HCPCS outpatient 238 178.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 211.82 89 999999999 185.64 226.1 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; EACH ADDITIONAL NAIL PLATE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11732_3 CDM 360 RC 11732 HCPCS outpatient 70 52.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 63 999999999 54.6 66.5 case rate "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; EACH ADDITIONAL NAIL PLATE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11732_3 CDM 360 RC 11732 HCPCS outpatient 70 52.5 AETNA MCR ADV AETNA MCR ADV 54.6 78 999999999 54.6 66.5 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; EACH ADDITIONAL NAIL PLATE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11732_3 CDM 360 RC 11732 HCPCS outpatient 70 52.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 61.3 87.57 999999999 54.6 66.5 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; EACH ADDITIONAL NAIL PLATE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11732_3 CDM 360 RC 11732 HCPCS outpatient 70 52.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 59.55 85.07 999999999 54.6 66.5 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; EACH ADDITIONAL NAIL PLATE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11732_3 CDM 360 RC 11732 HCPCS outpatient 70 52.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 59.55 85.07 999999999 54.6 66.5 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; EACH ADDITIONAL NAIL PLATE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11732_3 CDM 360 RC 11732 HCPCS outpatient 70 52.5 MOLINA MCAID MOLINA MCAID 58.38 83.4 999999999 54.6 66.5 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; EACH ADDITIONAL NAIL PLATE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11732_3 CDM 360 RC 11732 HCPCS outpatient 70 52.5 MOLINA MCR ADV MOLINA MCR ADV 62.3 89 999999999 54.6 66.5 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; EACH ADDITIONAL NAIL PLATE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11732_3 CDM 360 RC 11732 HCPCS outpatient 70 52.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 62.3 89 999999999 54.6 66.5 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; EACH ADDITIONAL NAIL PLATE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11732_3 CDM 360 RC 11732 HCPCS outpatient 70 52.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 62.3 89 999999999 54.6 66.5 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; EACH ADDITIONAL NAIL PLATE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11732_3 CDM 360 RC 11732 HCPCS outpatient 70 52.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 63 90 999999999 54.6 66.5 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; EACH ADDITIONAL NAIL PLATE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11732_3 CDM 360 RC 11732 HCPCS outpatient 70 52.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 66.5 95 999999999 54.6 66.5 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; EACH ADDITIONAL NAIL PLATE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11732_3 CDM 360 RC 11732 HCPCS outpatient 70 52.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 66.5 95 999999999 54.6 66.5 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; EACH ADDITIONAL NAIL PLATE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11732_3 CDM 360 RC 11732 HCPCS outpatient 70 52.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 62.3 89 999999999 54.6 66.5 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; EACH ADDITIONAL NAIL PLATE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11732_3 CDM 360 RC 11732 HCPCS outpatient 70 52.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 61.6 88 999999999 54.6 66.5 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; EACH ADDITIONAL NAIL PLATE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 11732_3 CDM 360 RC 11732 HCPCS outpatient 70 52.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 62.3 89 999999999 54.6 66.5 percent of total billed charges EVACUATION OF SUBUNGUAL HEMATOMA 11740_3 CDM 360 RC 11740 HCPCS outpatient 120 90 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 108 999999999 93.6 114 case rate EVACUATION OF SUBUNGUAL HEMATOMA 11740_3 CDM 360 RC 11740 HCPCS outpatient 120 90 AETNA MCR ADV AETNA MCR ADV 93.6 78 999999999 93.6 114 percent of total billed charges EVACUATION OF SUBUNGUAL HEMATOMA 11740_3 CDM 360 RC 11740 HCPCS outpatient 120 90 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 105.08 87.57 999999999 93.6 114 percent of total billed charges EVACUATION OF SUBUNGUAL HEMATOMA 11740_3 CDM 360 RC 11740 HCPCS outpatient 120 90 COORDINATED CARE MCAID COORDINATED CARE MCAID 102.08 85.07 999999999 93.6 114 percent of total billed charges EVACUATION OF SUBUNGUAL HEMATOMA 11740_3 CDM 360 RC 11740 HCPCS outpatient 120 90 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 102.08 85.07 999999999 93.6 114 percent of total billed charges EVACUATION OF SUBUNGUAL HEMATOMA 11740_3 CDM 360 RC 11740 HCPCS outpatient 120 90 MOLINA MCAID MOLINA MCAID 100.08 83.4 999999999 93.6 114 percent of total billed charges EVACUATION OF SUBUNGUAL HEMATOMA 11740_3 CDM 360 RC 11740 HCPCS outpatient 120 90 MOLINA MCR ADV MOLINA MCR ADV 106.8 89 999999999 93.6 114 percent of total billed charges EVACUATION OF SUBUNGUAL HEMATOMA 11740_3 CDM 360 RC 11740 HCPCS outpatient 120 90 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 106.8 89 999999999 93.6 114 percent of total billed charges EVACUATION OF SUBUNGUAL HEMATOMA 11740_3 CDM 360 RC 11740 HCPCS outpatient 120 90 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 106.8 89 999999999 93.6 114 percent of total billed charges EVACUATION OF SUBUNGUAL HEMATOMA 11740_3 CDM 360 RC 11740 HCPCS outpatient 120 90 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 108 90 999999999 93.6 114 percent of total billed charges EVACUATION OF SUBUNGUAL HEMATOMA 11740_3 CDM 360 RC 11740 HCPCS outpatient 120 90 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 114 95 999999999 93.6 114 percent of total billed charges EVACUATION OF SUBUNGUAL HEMATOMA 11740_3 CDM 360 RC 11740 HCPCS outpatient 120 90 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 114 95 999999999 93.6 114 percent of total billed charges EVACUATION OF SUBUNGUAL HEMATOMA 11740_3 CDM 360 RC 11740 HCPCS outpatient 120 90 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 106.8 89 999999999 93.6 114 percent of total billed charges EVACUATION OF SUBUNGUAL HEMATOMA 11740_3 CDM 360 RC 11740 HCPCS outpatient 120 90 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 105.6 88 999999999 93.6 114 percent of total billed charges EVACUATION OF SUBUNGUAL HEMATOMA 11740_3 CDM 360 RC 11740 HCPCS outpatient 120 90 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 106.8 89 999999999 93.6 114 percent of total billed charges "EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE (EG, INGROWN OR DEFORMED NAIL), FOR PERMANENT REMOVAL" 11750_3 CDM 360 RC 11750 HCPCS outpatient 330 247.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 297 999999999 257.4 313.5 case rate "EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE (EG, INGROWN OR DEFORMED NAIL), FOR PERMANENT REMOVAL" 11750_3 CDM 360 RC 11750 HCPCS outpatient 330 247.5 AETNA MCR ADV AETNA MCR ADV 257.4 78 999999999 257.4 313.5 percent of total billed charges "EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE (EG, INGROWN OR DEFORMED NAIL), FOR PERMANENT REMOVAL" 11750_3 CDM 360 RC 11750 HCPCS outpatient 330 247.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 288.98 87.57 999999999 257.4 313.5 percent of total billed charges "EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE (EG, INGROWN OR DEFORMED NAIL), FOR PERMANENT REMOVAL" 11750_3 CDM 360 RC 11750 HCPCS outpatient 330 247.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 280.73 85.07 999999999 257.4 313.5 percent of total billed charges "EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE (EG, INGROWN OR DEFORMED NAIL), FOR PERMANENT REMOVAL" 11750_3 CDM 360 RC 11750 HCPCS outpatient 330 247.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 280.73 85.07 999999999 257.4 313.5 percent of total billed charges "EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE (EG, INGROWN OR DEFORMED NAIL), FOR PERMANENT REMOVAL" 11750_3 CDM 360 RC 11750 HCPCS outpatient 330 247.5 MOLINA MCAID MOLINA MCAID 275.22 83.4 999999999 257.4 313.5 percent of total billed charges "EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE (EG, INGROWN OR DEFORMED NAIL), FOR PERMANENT REMOVAL" 11750_3 CDM 360 RC 11750 HCPCS outpatient 330 247.5 MOLINA MCR ADV MOLINA MCR ADV 293.7 89 999999999 257.4 313.5 percent of total billed charges "EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE (EG, INGROWN OR DEFORMED NAIL), FOR PERMANENT REMOVAL" 11750_3 CDM 360 RC 11750 HCPCS outpatient 330 247.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 293.7 89 999999999 257.4 313.5 percent of total billed charges "EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE (EG, INGROWN OR DEFORMED NAIL), FOR PERMANENT REMOVAL" 11750_3 CDM 360 RC 11750 HCPCS outpatient 330 247.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 293.7 89 999999999 257.4 313.5 percent of total billed charges "EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE (EG, INGROWN OR DEFORMED NAIL), FOR PERMANENT REMOVAL" 11750_3 CDM 360 RC 11750 HCPCS outpatient 330 247.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 297 90 999999999 257.4 313.5 percent of total billed charges "EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE (EG, INGROWN OR DEFORMED NAIL), FOR PERMANENT REMOVAL" 11750_3 CDM 360 RC 11750 HCPCS outpatient 330 247.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 313.5 95 999999999 257.4 313.5 percent of total billed charges "EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE (EG, INGROWN OR DEFORMED NAIL), FOR PERMANENT REMOVAL" 11750_3 CDM 360 RC 11750 HCPCS outpatient 330 247.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 313.5 95 999999999 257.4 313.5 percent of total billed charges "EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE (EG, INGROWN OR DEFORMED NAIL), FOR PERMANENT REMOVAL" 11750_3 CDM 360 RC 11750 HCPCS outpatient 330 247.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 293.7 89 999999999 257.4 313.5 percent of total billed charges "EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE (EG, INGROWN OR DEFORMED NAIL), FOR PERMANENT REMOVAL" 11750_3 CDM 360 RC 11750 HCPCS outpatient 330 247.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 290.4 88 999999999 257.4 313.5 percent of total billed charges "EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE (EG, INGROWN OR DEFORMED NAIL), FOR PERMANENT REMOVAL" 11750_3 CDM 360 RC 11750 HCPCS outpatient 330 247.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 293.7 89 999999999 257.4 313.5 percent of total billed charges REPAIR OF NAIL BED 11760_3 CDM 360 RC 11760 HCPCS outpatient 388 291 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 349.2 999999999 302.64 368.6 case rate REPAIR OF NAIL BED 11760_3 CDM 360 RC 11760 HCPCS outpatient 388 291 AETNA MCR ADV AETNA MCR ADV 302.64 78 999999999 302.64 368.6 percent of total billed charges REPAIR OF NAIL BED 11760_3 CDM 360 RC 11760 HCPCS outpatient 388 291 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 339.77 87.57 999999999 302.64 368.6 percent of total billed charges REPAIR OF NAIL BED 11760_3 CDM 360 RC 11760 HCPCS outpatient 388 291 COORDINATED CARE MCAID COORDINATED CARE MCAID 330.07 85.07 999999999 302.64 368.6 percent of total billed charges REPAIR OF NAIL BED 11760_3 CDM 360 RC 11760 HCPCS outpatient 388 291 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 330.07 85.07 999999999 302.64 368.6 percent of total billed charges REPAIR OF NAIL BED 11760_3 CDM 360 RC 11760 HCPCS outpatient 388 291 MOLINA MCAID MOLINA MCAID 323.59 83.4 999999999 302.64 368.6 percent of total billed charges REPAIR OF NAIL BED 11760_3 CDM 360 RC 11760 HCPCS outpatient 388 291 MOLINA MCR ADV MOLINA MCR ADV 345.32 89 999999999 302.64 368.6 percent of total billed charges REPAIR OF NAIL BED 11760_3 CDM 360 RC 11760 HCPCS outpatient 388 291 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 345.32 89 999999999 302.64 368.6 percent of total billed charges REPAIR OF NAIL BED 11760_3 CDM 360 RC 11760 HCPCS outpatient 388 291 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 345.32 89 999999999 302.64 368.6 percent of total billed charges REPAIR OF NAIL BED 11760_3 CDM 360 RC 11760 HCPCS outpatient 388 291 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 349.2 90 999999999 302.64 368.6 percent of total billed charges REPAIR OF NAIL BED 11760_3 CDM 360 RC 11760 HCPCS outpatient 388 291 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 368.6 95 999999999 302.64 368.6 percent of total billed charges REPAIR OF NAIL BED 11760_3 CDM 360 RC 11760 HCPCS outpatient 388 291 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 368.6 95 999999999 302.64 368.6 percent of total billed charges REPAIR OF NAIL BED 11760_3 CDM 360 RC 11760 HCPCS outpatient 388 291 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 345.32 89 999999999 302.64 368.6 percent of total billed charges REPAIR OF NAIL BED 11760_3 CDM 360 RC 11760 HCPCS outpatient 388 291 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 341.44 88 999999999 302.64 368.6 percent of total billed charges REPAIR OF NAIL BED 11760_3 CDM 360 RC 11760 HCPCS outpatient 388 291 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 345.32 89 999999999 302.64 368.6 percent of total billed charges "WEDGE EXCISION OF SKIN OF NAIL FOLD (EG, FOR INGROWN TOENAIL)" 11765_3 CDM 360 RC 11765 HCPCS outpatient 344 258 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 309.6 999999999 268.32 326.8 case rate "WEDGE EXCISION OF SKIN OF NAIL FOLD (EG, FOR INGROWN TOENAIL)" 11765_3 CDM 360 RC 11765 HCPCS outpatient 344 258 AETNA MCR ADV AETNA MCR ADV 268.32 78 999999999 268.32 326.8 percent of total billed charges "WEDGE EXCISION OF SKIN OF NAIL FOLD (EG, FOR INGROWN TOENAIL)" 11765_3 CDM 360 RC 11765 HCPCS outpatient 344 258 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 301.24 87.57 999999999 268.32 326.8 percent of total billed charges "WEDGE EXCISION OF SKIN OF NAIL FOLD (EG, FOR INGROWN TOENAIL)" 11765_3 CDM 360 RC 11765 HCPCS outpatient 344 258 COORDINATED CARE MCAID COORDINATED CARE MCAID 292.64 85.07 999999999 268.32 326.8 percent of total billed charges "WEDGE EXCISION OF SKIN OF NAIL FOLD (EG, FOR INGROWN TOENAIL)" 11765_3 CDM 360 RC 11765 HCPCS outpatient 344 258 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 292.64 85.07 999999999 268.32 326.8 percent of total billed charges "WEDGE EXCISION OF SKIN OF NAIL FOLD (EG, FOR INGROWN TOENAIL)" 11765_3 CDM 360 RC 11765 HCPCS outpatient 344 258 MOLINA MCAID MOLINA MCAID 286.9 83.4 999999999 268.32 326.8 percent of total billed charges "WEDGE EXCISION OF SKIN OF NAIL FOLD (EG, FOR INGROWN TOENAIL)" 11765_3 CDM 360 RC 11765 HCPCS outpatient 344 258 MOLINA MCR ADV MOLINA MCR ADV 306.16 89 999999999 268.32 326.8 percent of total billed charges "WEDGE EXCISION OF SKIN OF NAIL FOLD (EG, FOR INGROWN TOENAIL)" 11765_3 CDM 360 RC 11765 HCPCS outpatient 344 258 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 306.16 89 999999999 268.32 326.8 percent of total billed charges "WEDGE EXCISION OF SKIN OF NAIL FOLD (EG, FOR INGROWN TOENAIL)" 11765_3 CDM 360 RC 11765 HCPCS outpatient 344 258 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 306.16 89 999999999 268.32 326.8 percent of total billed charges "WEDGE EXCISION OF SKIN OF NAIL FOLD (EG, FOR INGROWN TOENAIL)" 11765_3 CDM 360 RC 11765 HCPCS outpatient 344 258 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 309.6 90 999999999 268.32 326.8 percent of total billed charges "WEDGE EXCISION OF SKIN OF NAIL FOLD (EG, FOR INGROWN TOENAIL)" 11765_3 CDM 360 RC 11765 HCPCS outpatient 344 258 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 326.8 95 999999999 268.32 326.8 percent of total billed charges "WEDGE EXCISION OF SKIN OF NAIL FOLD (EG, FOR INGROWN TOENAIL)" 11765_3 CDM 360 RC 11765 HCPCS outpatient 344 258 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 326.8 95 999999999 268.32 326.8 percent of total billed charges "WEDGE EXCISION OF SKIN OF NAIL FOLD (EG, FOR INGROWN TOENAIL)" 11765_3 CDM 360 RC 11765 HCPCS outpatient 344 258 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 306.16 89 999999999 268.32 326.8 percent of total billed charges "WEDGE EXCISION OF SKIN OF NAIL FOLD (EG, FOR INGROWN TOENAIL)" 11765_3 CDM 360 RC 11765 HCPCS outpatient 344 258 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 302.72 88 999999999 268.32 326.8 percent of total billed charges "WEDGE EXCISION OF SKIN OF NAIL FOLD (EG, FOR INGROWN TOENAIL)" 11765_3 CDM 360 RC 11765 HCPCS outpatient 344 258 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 306.16 89 999999999 268.32 326.8 percent of total billed charges "REMOVAL, IMPLANTABLE CONTRACEPTIVE CAPSULES" 11976_3 CDM 360 RC 11976 HCPCS outpatient 294 220.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 264.6 999999999 229.32 279.3 case rate "REMOVAL, IMPLANTABLE CONTRACEPTIVE CAPSULES" 11976_3 CDM 360 RC 11976 HCPCS outpatient 294 220.5 AETNA MCR ADV AETNA MCR ADV 229.32 78 999999999 229.32 279.3 percent of total billed charges "REMOVAL, IMPLANTABLE CONTRACEPTIVE CAPSULES" 11976_3 CDM 360 RC 11976 HCPCS outpatient 294 220.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 257.46 87.57 999999999 229.32 279.3 percent of total billed charges "REMOVAL, IMPLANTABLE CONTRACEPTIVE CAPSULES" 11976_3 CDM 360 RC 11976 HCPCS outpatient 294 220.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 250.11 85.07 999999999 229.32 279.3 percent of total billed charges "REMOVAL, IMPLANTABLE CONTRACEPTIVE CAPSULES" 11976_3 CDM 360 RC 11976 HCPCS outpatient 294 220.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 250.11 85.07 999999999 229.32 279.3 percent of total billed charges "REMOVAL, IMPLANTABLE CONTRACEPTIVE CAPSULES" 11976_3 CDM 360 RC 11976 HCPCS outpatient 294 220.5 MOLINA MCAID MOLINA MCAID 245.2 83.4 999999999 229.32 279.3 percent of total billed charges "REMOVAL, IMPLANTABLE CONTRACEPTIVE CAPSULES" 11976_3 CDM 360 RC 11976 HCPCS outpatient 294 220.5 MOLINA MCR ADV MOLINA MCR ADV 261.66 89 999999999 229.32 279.3 percent of total billed charges "REMOVAL, IMPLANTABLE CONTRACEPTIVE CAPSULES" 11976_3 CDM 360 RC 11976 HCPCS outpatient 294 220.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 261.66 89 999999999 229.32 279.3 percent of total billed charges "REMOVAL, IMPLANTABLE CONTRACEPTIVE CAPSULES" 11976_3 CDM 360 RC 11976 HCPCS outpatient 294 220.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 261.66 89 999999999 229.32 279.3 percent of total billed charges "REMOVAL, IMPLANTABLE CONTRACEPTIVE CAPSULES" 11976_3 CDM 360 RC 11976 HCPCS outpatient 294 220.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 264.6 90 999999999 229.32 279.3 percent of total billed charges "REMOVAL, IMPLANTABLE CONTRACEPTIVE CAPSULES" 11976_3 CDM 360 RC 11976 HCPCS outpatient 294 220.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 279.3 95 999999999 229.32 279.3 percent of total billed charges "REMOVAL, IMPLANTABLE CONTRACEPTIVE CAPSULES" 11976_3 CDM 360 RC 11976 HCPCS outpatient 294 220.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 279.3 95 999999999 229.32 279.3 percent of total billed charges "REMOVAL, IMPLANTABLE CONTRACEPTIVE CAPSULES" 11976_3 CDM 360 RC 11976 HCPCS outpatient 294 220.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 261.66 89 999999999 229.32 279.3 percent of total billed charges "REMOVAL, IMPLANTABLE CONTRACEPTIVE CAPSULES" 11976_3 CDM 360 RC 11976 HCPCS outpatient 294 220.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 258.72 88 999999999 229.32 279.3 percent of total billed charges "REMOVAL, IMPLANTABLE CONTRACEPTIVE CAPSULES" 11976_3 CDM 360 RC 11976 HCPCS outpatient 294 220.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 261.66 89 999999999 229.32 279.3 percent of total billed charges "REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT" 11982_3 CDM 360 RC 11982 HCPCS outpatient 231 173.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 207.9 999999999 180.18 219.45 case rate "REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT" 11982_3 CDM 360 RC 11982 HCPCS outpatient 231 173.25 AETNA MCR ADV AETNA MCR ADV 180.18 78 999999999 180.18 219.45 percent of total billed charges "REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT" 11982_3 CDM 360 RC 11982 HCPCS outpatient 231 173.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 202.29 87.57 999999999 180.18 219.45 percent of total billed charges "REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT" 11982_3 CDM 360 RC 11982 HCPCS outpatient 231 173.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 196.51 85.07 999999999 180.18 219.45 percent of total billed charges "REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT" 11982_3 CDM 360 RC 11982 HCPCS outpatient 231 173.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 196.51 85.07 999999999 180.18 219.45 percent of total billed charges "REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT" 11982_3 CDM 360 RC 11982 HCPCS outpatient 231 173.25 MOLINA MCAID MOLINA MCAID 192.65 83.4 999999999 180.18 219.45 percent of total billed charges "REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT" 11982_3 CDM 360 RC 11982 HCPCS outpatient 231 173.25 MOLINA MCR ADV MOLINA MCR ADV 205.59 89 999999999 180.18 219.45 percent of total billed charges "REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT" 11982_3 CDM 360 RC 11982 HCPCS outpatient 231 173.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 205.59 89 999999999 180.18 219.45 percent of total billed charges "REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT" 11982_3 CDM 360 RC 11982 HCPCS outpatient 231 173.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 205.59 89 999999999 180.18 219.45 percent of total billed charges "REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT" 11982_3 CDM 360 RC 11982 HCPCS outpatient 231 173.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 207.9 90 999999999 180.18 219.45 percent of total billed charges "REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT" 11982_3 CDM 360 RC 11982 HCPCS outpatient 231 173.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 219.45 95 999999999 180.18 219.45 percent of total billed charges "REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT" 11982_3 CDM 360 RC 11982 HCPCS outpatient 231 173.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 219.45 95 999999999 180.18 219.45 percent of total billed charges "REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT" 11982_3 CDM 360 RC 11982 HCPCS outpatient 231 173.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 205.59 89 999999999 180.18 219.45 percent of total billed charges "REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT" 11982_3 CDM 360 RC 11982 HCPCS outpatient 231 173.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 203.28 88 999999999 180.18 219.45 percent of total billed charges "REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT" 11982_3 CDM 360 RC 11982 HCPCS outpatient 231 173.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 205.59 89 999999999 180.18 219.45 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_1 CDM 360 RC 12001 HCPCS outpatient 134.04 100.53 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 120.64 999999999 104.55 127.34 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_1 CDM 360 RC 12001 HCPCS outpatient 134.04 100.53 AETNA MCR ADV AETNA MCR ADV 104.55 78 999999999 104.55 127.34 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_1 CDM 360 RC 12001 HCPCS outpatient 134.04 100.53 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 117.38 87.57 999999999 104.55 127.34 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_1 CDM 360 RC 12001 HCPCS outpatient 134.04 100.53 COORDINATED CARE MCAID COORDINATED CARE MCAID 114.03 85.07 999999999 104.55 127.34 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_1 CDM 360 RC 12001 HCPCS outpatient 134.04 100.53 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 114.03 85.07 999999999 104.55 127.34 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_1 CDM 360 RC 12001 HCPCS outpatient 134.04 100.53 MOLINA MCAID MOLINA MCAID 111.79 83.4 999999999 104.55 127.34 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_1 CDM 360 RC 12001 HCPCS outpatient 134.04 100.53 MOLINA MCR ADV MOLINA MCR ADV 119.3 89 999999999 104.55 127.34 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_1 CDM 360 RC 12001 HCPCS outpatient 134.04 100.53 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 119.3 89 999999999 104.55 127.34 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_1 CDM 360 RC 12001 HCPCS outpatient 134.04 100.53 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 119.3 89 999999999 104.55 127.34 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_1 CDM 360 RC 12001 HCPCS outpatient 134.04 100.53 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 120.64 90 999999999 104.55 127.34 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_1 CDM 360 RC 12001 HCPCS outpatient 134.04 100.53 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 127.34 95 999999999 104.55 127.34 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_1 CDM 360 RC 12001 HCPCS outpatient 134.04 100.53 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 127.34 95 999999999 104.55 127.34 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_1 CDM 360 RC 12001 HCPCS outpatient 134.04 100.53 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 119.3 89 999999999 104.55 127.34 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_1 CDM 360 RC 12001 HCPCS outpatient 134.04 100.53 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 117.96 88 999999999 104.55 127.34 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_1 CDM 360 RC 12001 HCPCS outpatient 134.04 100.53 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 119.3 89 999999999 104.55 127.34 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_2 CDM 360 RC 12001 HCPCS outpatient 134.04 100.53 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 120.64 999999999 104.55 127.34 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_2 CDM 360 RC 12001 HCPCS outpatient 134.04 100.53 AETNA MCR ADV AETNA MCR ADV 104.55 78 999999999 104.55 127.34 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_2 CDM 360 RC 12001 HCPCS outpatient 134.04 100.53 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 117.38 87.57 999999999 104.55 127.34 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_2 CDM 360 RC 12001 HCPCS outpatient 134.04 100.53 COORDINATED CARE MCAID COORDINATED CARE MCAID 114.03 85.07 999999999 104.55 127.34 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_2 CDM 360 RC 12001 HCPCS outpatient 134.04 100.53 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 114.03 85.07 999999999 104.55 127.34 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_2 CDM 360 RC 12001 HCPCS outpatient 134.04 100.53 MOLINA MCAID MOLINA MCAID 111.79 83.4 999999999 104.55 127.34 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_2 CDM 360 RC 12001 HCPCS outpatient 134.04 100.53 MOLINA MCR ADV MOLINA MCR ADV 119.3 89 999999999 104.55 127.34 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_2 CDM 360 RC 12001 HCPCS outpatient 134.04 100.53 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 119.3 89 999999999 104.55 127.34 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_2 CDM 360 RC 12001 HCPCS outpatient 134.04 100.53 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 119.3 89 999999999 104.55 127.34 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_2 CDM 360 RC 12001 HCPCS outpatient 134.04 100.53 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 120.64 90 999999999 104.55 127.34 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_2 CDM 360 RC 12001 HCPCS outpatient 134.04 100.53 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 127.34 95 999999999 104.55 127.34 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_2 CDM 360 RC 12001 HCPCS outpatient 134.04 100.53 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 127.34 95 999999999 104.55 127.34 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_2 CDM 360 RC 12001 HCPCS outpatient 134.04 100.53 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 119.3 89 999999999 104.55 127.34 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_2 CDM 360 RC 12001 HCPCS outpatient 134.04 100.53 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 117.96 88 999999999 104.55 127.34 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_2 CDM 360 RC 12001 HCPCS outpatient 134.04 100.53 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 119.3 89 999999999 104.55 127.34 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_3 CDM 360 RC 12001 HCPCS outpatient 193 144.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 173.7 999999999 150.54 183.35 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_3 CDM 360 RC 12001 HCPCS outpatient 193 144.75 AETNA MCR ADV AETNA MCR ADV 150.54 78 999999999 150.54 183.35 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_3 CDM 360 RC 12001 HCPCS outpatient 193 144.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 169.01 87.57 999999999 150.54 183.35 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_3 CDM 360 RC 12001 HCPCS outpatient 193 144.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 164.19 85.07 999999999 150.54 183.35 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_3 CDM 360 RC 12001 HCPCS outpatient 193 144.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 164.19 85.07 999999999 150.54 183.35 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_3 CDM 360 RC 12001 HCPCS outpatient 193 144.75 MOLINA MCAID MOLINA MCAID 160.96 83.4 999999999 150.54 183.35 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_3 CDM 360 RC 12001 HCPCS outpatient 193 144.75 MOLINA MCR ADV MOLINA MCR ADV 171.77 89 999999999 150.54 183.35 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_3 CDM 360 RC 12001 HCPCS outpatient 193 144.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 171.77 89 999999999 150.54 183.35 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_3 CDM 360 RC 12001 HCPCS outpatient 193 144.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 171.77 89 999999999 150.54 183.35 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_3 CDM 360 RC 12001 HCPCS outpatient 193 144.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 173.7 90 999999999 150.54 183.35 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_3 CDM 360 RC 12001 HCPCS outpatient 193 144.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 183.35 95 999999999 150.54 183.35 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_3 CDM 360 RC 12001 HCPCS outpatient 193 144.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 183.35 95 999999999 150.54 183.35 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_3 CDM 360 RC 12001 HCPCS outpatient 193 144.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 171.77 89 999999999 150.54 183.35 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_3 CDM 360 RC 12001 HCPCS outpatient 193 144.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 169.84 88 999999999 150.54 183.35 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12001_3 CDM 360 RC 12001 HCPCS outpatient 193 144.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 171.77 89 999999999 150.54 183.35 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_1 CDM 360 RC 12002 HCPCS outpatient 175.35 131.51 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 157.82 999999999 136.77 166.58 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_1 CDM 360 RC 12002 HCPCS outpatient 175.35 131.51 AETNA MCR ADV AETNA MCR ADV 136.77 78 999999999 136.77 166.58 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_1 CDM 360 RC 12002 HCPCS outpatient 175.35 131.51 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 153.55 87.57 999999999 136.77 166.58 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_1 CDM 360 RC 12002 HCPCS outpatient 175.35 131.51 COORDINATED CARE MCAID COORDINATED CARE MCAID 149.17 85.07 999999999 136.77 166.58 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_1 CDM 360 RC 12002 HCPCS outpatient 175.35 131.51 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 149.17 85.07 999999999 136.77 166.58 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_1 CDM 360 RC 12002 HCPCS outpatient 175.35 131.51 MOLINA MCAID MOLINA MCAID 146.24 83.4 999999999 136.77 166.58 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_1 CDM 360 RC 12002 HCPCS outpatient 175.35 131.51 MOLINA MCR ADV MOLINA MCR ADV 156.06 89 999999999 136.77 166.58 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_1 CDM 360 RC 12002 HCPCS outpatient 175.35 131.51 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 156.06 89 999999999 136.77 166.58 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_1 CDM 360 RC 12002 HCPCS outpatient 175.35 131.51 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 156.06 89 999999999 136.77 166.58 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_1 CDM 360 RC 12002 HCPCS outpatient 175.35 131.51 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 157.82 90 999999999 136.77 166.58 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_1 CDM 360 RC 12002 HCPCS outpatient 175.35 131.51 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 166.58 95 999999999 136.77 166.58 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_1 CDM 360 RC 12002 HCPCS outpatient 175.35 131.51 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 166.58 95 999999999 136.77 166.58 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_1 CDM 360 RC 12002 HCPCS outpatient 175.35 131.51 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 156.06 89 999999999 136.77 166.58 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_1 CDM 360 RC 12002 HCPCS outpatient 175.35 131.51 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 154.31 88 999999999 136.77 166.58 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_1 CDM 360 RC 12002 HCPCS outpatient 175.35 131.51 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 156.06 89 999999999 136.77 166.58 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_2 CDM 360 RC 12002 HCPCS outpatient 175.35 131.51 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 157.82 999999999 136.77 166.58 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_2 CDM 360 RC 12002 HCPCS outpatient 175.35 131.51 AETNA MCR ADV AETNA MCR ADV 136.77 78 999999999 136.77 166.58 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_2 CDM 360 RC 12002 HCPCS outpatient 175.35 131.51 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 153.55 87.57 999999999 136.77 166.58 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_2 CDM 360 RC 12002 HCPCS outpatient 175.35 131.51 COORDINATED CARE MCAID COORDINATED CARE MCAID 149.17 85.07 999999999 136.77 166.58 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_2 CDM 360 RC 12002 HCPCS outpatient 175.35 131.51 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 149.17 85.07 999999999 136.77 166.58 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_2 CDM 360 RC 12002 HCPCS outpatient 175.35 131.51 MOLINA MCAID MOLINA MCAID 146.24 83.4 999999999 136.77 166.58 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_2 CDM 360 RC 12002 HCPCS outpatient 175.35 131.51 MOLINA MCR ADV MOLINA MCR ADV 156.06 89 999999999 136.77 166.58 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_2 CDM 360 RC 12002 HCPCS outpatient 175.35 131.51 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 156.06 89 999999999 136.77 166.58 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_2 CDM 360 RC 12002 HCPCS outpatient 175.35 131.51 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 156.06 89 999999999 136.77 166.58 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_2 CDM 360 RC 12002 HCPCS outpatient 175.35 131.51 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 157.82 90 999999999 136.77 166.58 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_2 CDM 360 RC 12002 HCPCS outpatient 175.35 131.51 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 166.58 95 999999999 136.77 166.58 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_2 CDM 360 RC 12002 HCPCS outpatient 175.35 131.51 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 166.58 95 999999999 136.77 166.58 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_2 CDM 360 RC 12002 HCPCS outpatient 175.35 131.51 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 156.06 89 999999999 136.77 166.58 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_2 CDM 360 RC 12002 HCPCS outpatient 175.35 131.51 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 154.31 88 999999999 136.77 166.58 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_2 CDM 360 RC 12002 HCPCS outpatient 175.35 131.51 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 156.06 89 999999999 136.77 166.58 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_3 CDM 360 RC 12002 HCPCS outpatient 232 174 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 208.8 999999999 180.96 220.4 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_3 CDM 360 RC 12002 HCPCS outpatient 232 174 AETNA MCR ADV AETNA MCR ADV 180.96 78 999999999 180.96 220.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_3 CDM 360 RC 12002 HCPCS outpatient 232 174 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 203.16 87.57 999999999 180.96 220.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_3 CDM 360 RC 12002 HCPCS outpatient 232 174 COORDINATED CARE MCAID COORDINATED CARE MCAID 197.36 85.07 999999999 180.96 220.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_3 CDM 360 RC 12002 HCPCS outpatient 232 174 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 197.36 85.07 999999999 180.96 220.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_3 CDM 360 RC 12002 HCPCS outpatient 232 174 MOLINA MCAID MOLINA MCAID 193.49 83.4 999999999 180.96 220.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_3 CDM 360 RC 12002 HCPCS outpatient 232 174 MOLINA MCR ADV MOLINA MCR ADV 206.48 89 999999999 180.96 220.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_3 CDM 360 RC 12002 HCPCS outpatient 232 174 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 206.48 89 999999999 180.96 220.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_3 CDM 360 RC 12002 HCPCS outpatient 232 174 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 206.48 89 999999999 180.96 220.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_3 CDM 360 RC 12002 HCPCS outpatient 232 174 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 208.8 90 999999999 180.96 220.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_3 CDM 360 RC 12002 HCPCS outpatient 232 174 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 220.4 95 999999999 180.96 220.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_3 CDM 360 RC 12002 HCPCS outpatient 232 174 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 220.4 95 999999999 180.96 220.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_3 CDM 360 RC 12002 HCPCS outpatient 232 174 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 206.48 89 999999999 180.96 220.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_3 CDM 360 RC 12002 HCPCS outpatient 232 174 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 204.16 88 999999999 180.96 220.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12002_3 CDM 360 RC 12002 HCPCS outpatient 232 174 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 206.48 89 999999999 180.96 220.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12004_1 CDM 360 RC 12004 HCPCS outpatient 216.66 162.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 194.99 999999999 168.99 205.83 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12004_1 CDM 360 RC 12004 HCPCS outpatient 216.66 162.5 AETNA MCR ADV AETNA MCR ADV 168.99 78 999999999 168.99 205.83 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12004_1 CDM 360 RC 12004 HCPCS outpatient 216.66 162.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 189.73 87.57 999999999 168.99 205.83 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12004_1 CDM 360 RC 12004 HCPCS outpatient 216.66 162.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 184.31 85.07 999999999 168.99 205.83 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12004_1 CDM 360 RC 12004 HCPCS outpatient 216.66 162.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 184.31 85.07 999999999 168.99 205.83 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12004_1 CDM 360 RC 12004 HCPCS outpatient 216.66 162.5 MOLINA MCAID MOLINA MCAID 180.69 83.4 999999999 168.99 205.83 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12004_1 CDM 360 RC 12004 HCPCS outpatient 216.66 162.5 MOLINA MCR ADV MOLINA MCR ADV 192.83 89 999999999 168.99 205.83 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12004_1 CDM 360 RC 12004 HCPCS outpatient 216.66 162.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 192.83 89 999999999 168.99 205.83 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12004_1 CDM 360 RC 12004 HCPCS outpatient 216.66 162.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 192.83 89 999999999 168.99 205.83 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12004_1 CDM 360 RC 12004 HCPCS outpatient 216.66 162.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 194.99 90 999999999 168.99 205.83 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12004_1 CDM 360 RC 12004 HCPCS outpatient 216.66 162.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 205.83 95 999999999 168.99 205.83 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12004_1 CDM 360 RC 12004 HCPCS outpatient 216.66 162.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 205.83 95 999999999 168.99 205.83 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12004_1 CDM 360 RC 12004 HCPCS outpatient 216.66 162.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 192.83 89 999999999 168.99 205.83 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12004_1 CDM 360 RC 12004 HCPCS outpatient 216.66 162.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 190.66 88 999999999 168.99 205.83 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12004_1 CDM 360 RC 12004 HCPCS outpatient 216.66 162.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 192.83 89 999999999 168.99 205.83 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12004_2 CDM 360 RC 12004 HCPCS outpatient 216.66 162.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 194.99 999999999 168.99 205.83 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12004_2 CDM 360 RC 12004 HCPCS outpatient 216.66 162.5 AETNA MCR ADV AETNA MCR ADV 168.99 78 999999999 168.99 205.83 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12004_2 CDM 360 RC 12004 HCPCS outpatient 216.66 162.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 189.73 87.57 999999999 168.99 205.83 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12004_2 CDM 360 RC 12004 HCPCS outpatient 216.66 162.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 184.31 85.07 999999999 168.99 205.83 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12004_2 CDM 360 RC 12004 HCPCS outpatient 216.66 162.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 184.31 85.07 999999999 168.99 205.83 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12004_2 CDM 360 RC 12004 HCPCS outpatient 216.66 162.5 MOLINA MCAID MOLINA MCAID 180.69 83.4 999999999 168.99 205.83 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12004_2 CDM 360 RC 12004 HCPCS outpatient 216.66 162.5 MOLINA MCR ADV MOLINA MCR ADV 192.83 89 999999999 168.99 205.83 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12004_2 CDM 360 RC 12004 HCPCS outpatient 216.66 162.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 192.83 89 999999999 168.99 205.83 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12004_2 CDM 360 RC 12004 HCPCS outpatient 216.66 162.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 192.83 89 999999999 168.99 205.83 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12004_2 CDM 360 RC 12004 HCPCS outpatient 216.66 162.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 194.99 90 999999999 168.99 205.83 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12004_2 CDM 360 RC 12004 HCPCS outpatient 216.66 162.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 205.83 95 999999999 168.99 205.83 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12004_2 CDM 360 RC 12004 HCPCS outpatient 216.66 162.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 205.83 95 999999999 168.99 205.83 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12004_2 CDM 360 RC 12004 HCPCS outpatient 216.66 162.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 192.83 89 999999999 168.99 205.83 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12004_2 CDM 360 RC 12004 HCPCS outpatient 216.66 162.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 190.66 88 999999999 168.99 205.83 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12004_2 CDM 360 RC 12004 HCPCS outpatient 216.66 162.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 192.83 89 999999999 168.99 205.83 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12005_1 CDM 360 RC 12005 HCPCS outpatient 282.03 211.52 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 253.83 999999999 219.98 267.93 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12005_1 CDM 360 RC 12005 HCPCS outpatient 282.03 211.52 AETNA MCR ADV AETNA MCR ADV 219.98 78 999999999 219.98 267.93 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12005_1 CDM 360 RC 12005 HCPCS outpatient 282.03 211.52 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 246.97 87.57 999999999 219.98 267.93 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12005_1 CDM 360 RC 12005 HCPCS outpatient 282.03 211.52 COORDINATED CARE MCAID COORDINATED CARE MCAID 239.92 85.07 999999999 219.98 267.93 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12005_1 CDM 360 RC 12005 HCPCS outpatient 282.03 211.52 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 239.92 85.07 999999999 219.98 267.93 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12005_1 CDM 360 RC 12005 HCPCS outpatient 282.03 211.52 MOLINA MCAID MOLINA MCAID 235.21 83.4 999999999 219.98 267.93 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12005_1 CDM 360 RC 12005 HCPCS outpatient 282.03 211.52 MOLINA MCR ADV MOLINA MCR ADV 251.01 89 999999999 219.98 267.93 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12005_1 CDM 360 RC 12005 HCPCS outpatient 282.03 211.52 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 251.01 89 999999999 219.98 267.93 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12005_1 CDM 360 RC 12005 HCPCS outpatient 282.03 211.52 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 251.01 89 999999999 219.98 267.93 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12005_1 CDM 360 RC 12005 HCPCS outpatient 282.03 211.52 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 253.83 90 999999999 219.98 267.93 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12005_1 CDM 360 RC 12005 HCPCS outpatient 282.03 211.52 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 267.93 95 999999999 219.98 267.93 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12005_1 CDM 360 RC 12005 HCPCS outpatient 282.03 211.52 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 267.93 95 999999999 219.98 267.93 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12005_1 CDM 360 RC 12005 HCPCS outpatient 282.03 211.52 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 251.01 89 999999999 219.98 267.93 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12005_1 CDM 360 RC 12005 HCPCS outpatient 282.03 211.52 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 248.19 88 999999999 219.98 267.93 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12005_1 CDM 360 RC 12005 HCPCS outpatient 282.03 211.52 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 251.01 89 999999999 219.98 267.93 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12005_3 CDM 360 RC 12005 HCPCS outpatient 360 270 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 324 999999999 280.8 342 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12005_3 CDM 360 RC 12005 HCPCS outpatient 360 270 AETNA MCR ADV AETNA MCR ADV 280.8 78 999999999 280.8 342 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12005_3 CDM 360 RC 12005 HCPCS outpatient 360 270 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 315.25 87.57 999999999 280.8 342 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12005_3 CDM 360 RC 12005 HCPCS outpatient 360 270 COORDINATED CARE MCAID COORDINATED CARE MCAID 306.25 85.07 999999999 280.8 342 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12005_3 CDM 360 RC 12005 HCPCS outpatient 360 270 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 306.25 85.07 999999999 280.8 342 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12005_3 CDM 360 RC 12005 HCPCS outpatient 360 270 MOLINA MCAID MOLINA MCAID 300.24 83.4 999999999 280.8 342 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12005_3 CDM 360 RC 12005 HCPCS outpatient 360 270 MOLINA MCR ADV MOLINA MCR ADV 320.4 89 999999999 280.8 342 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12005_3 CDM 360 RC 12005 HCPCS outpatient 360 270 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 320.4 89 999999999 280.8 342 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12005_3 CDM 360 RC 12005 HCPCS outpatient 360 270 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 320.4 89 999999999 280.8 342 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12005_3 CDM 360 RC 12005 HCPCS outpatient 360 270 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 324 90 999999999 280.8 342 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12005_3 CDM 360 RC 12005 HCPCS outpatient 360 270 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 342 95 999999999 280.8 342 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12005_3 CDM 360 RC 12005 HCPCS outpatient 360 270 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 342 95 999999999 280.8 342 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12005_3 CDM 360 RC 12005 HCPCS outpatient 360 270 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 320.4 89 999999999 280.8 342 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12005_3 CDM 360 RC 12005 HCPCS outpatient 360 270 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 316.8 88 999999999 280.8 342 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12005_3 CDM 360 RC 12005 HCPCS outpatient 360 270 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 320.4 89 999999999 280.8 342 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 12006_1 CDM 360 RC 12006 HCPCS outpatient 346.53 259.9 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 311.88 999999999 270.29 329.2 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 12006_1 CDM 360 RC 12006 HCPCS outpatient 346.53 259.9 AETNA MCR ADV AETNA MCR ADV 270.29 78 999999999 270.29 329.2 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 12006_1 CDM 360 RC 12006 HCPCS outpatient 346.53 259.9 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 303.46 87.57 999999999 270.29 329.2 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 12006_1 CDM 360 RC 12006 HCPCS outpatient 346.53 259.9 COORDINATED CARE MCAID COORDINATED CARE MCAID 294.79 85.07 999999999 270.29 329.2 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 12006_1 CDM 360 RC 12006 HCPCS outpatient 346.53 259.9 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 294.79 85.07 999999999 270.29 329.2 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 12006_1 CDM 360 RC 12006 HCPCS outpatient 346.53 259.9 MOLINA MCAID MOLINA MCAID 289.01 83.4 999999999 270.29 329.2 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 12006_1 CDM 360 RC 12006 HCPCS outpatient 346.53 259.9 MOLINA MCR ADV MOLINA MCR ADV 308.41 89 999999999 270.29 329.2 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 12006_1 CDM 360 RC 12006 HCPCS outpatient 346.53 259.9 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 308.41 89 999999999 270.29 329.2 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 12006_1 CDM 360 RC 12006 HCPCS outpatient 346.53 259.9 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 308.41 89 999999999 270.29 329.2 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 12006_1 CDM 360 RC 12006 HCPCS outpatient 346.53 259.9 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 311.88 90 999999999 270.29 329.2 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 12006_1 CDM 360 RC 12006 HCPCS outpatient 346.53 259.9 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 329.2 95 999999999 270.29 329.2 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 12006_1 CDM 360 RC 12006 HCPCS outpatient 346.53 259.9 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 329.2 95 999999999 270.29 329.2 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 12006_1 CDM 360 RC 12006 HCPCS outpatient 346.53 259.9 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 308.41 89 999999999 270.29 329.2 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 12006_1 CDM 360 RC 12006 HCPCS outpatient 346.53 259.9 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 304.95 88 999999999 270.29 329.2 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 12006_1 CDM 360 RC 12006 HCPCS outpatient 346.53 259.9 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 308.41 89 999999999 270.29 329.2 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); OVER 30.0 CM" 12007_3 CDM 360 RC 12007 HCPCS outpatient 472 354 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 424.8 999999999 368.16 448.4 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); OVER 30.0 CM" 12007_3 CDM 360 RC 12007 HCPCS outpatient 472 354 AETNA MCR ADV AETNA MCR ADV 368.16 78 999999999 368.16 448.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); OVER 30.0 CM" 12007_3 CDM 360 RC 12007 HCPCS outpatient 472 354 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 413.33 87.57 999999999 368.16 448.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); OVER 30.0 CM" 12007_3 CDM 360 RC 12007 HCPCS outpatient 472 354 COORDINATED CARE MCAID COORDINATED CARE MCAID 401.53 85.07 999999999 368.16 448.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); OVER 30.0 CM" 12007_3 CDM 360 RC 12007 HCPCS outpatient 472 354 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 401.53 85.07 999999999 368.16 448.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); OVER 30.0 CM" 12007_3 CDM 360 RC 12007 HCPCS outpatient 472 354 MOLINA MCAID MOLINA MCAID 393.65 83.4 999999999 368.16 448.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); OVER 30.0 CM" 12007_3 CDM 360 RC 12007 HCPCS outpatient 472 354 MOLINA MCR ADV MOLINA MCR ADV 420.08 89 999999999 368.16 448.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); OVER 30.0 CM" 12007_3 CDM 360 RC 12007 HCPCS outpatient 472 354 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 420.08 89 999999999 368.16 448.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); OVER 30.0 CM" 12007_3 CDM 360 RC 12007 HCPCS outpatient 472 354 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 420.08 89 999999999 368.16 448.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); OVER 30.0 CM" 12007_3 CDM 360 RC 12007 HCPCS outpatient 472 354 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 424.8 90 999999999 368.16 448.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); OVER 30.0 CM" 12007_3 CDM 360 RC 12007 HCPCS outpatient 472 354 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 448.4 95 999999999 368.16 448.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); OVER 30.0 CM" 12007_3 CDM 360 RC 12007 HCPCS outpatient 472 354 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 448.4 95 999999999 368.16 448.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); OVER 30.0 CM" 12007_3 CDM 360 RC 12007 HCPCS outpatient 472 354 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 420.08 89 999999999 368.16 448.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); OVER 30.0 CM" 12007_3 CDM 360 RC 12007 HCPCS outpatient 472 354 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 415.36 88 999999999 368.16 448.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); OVER 30.0 CM" 12007_3 CDM 360 RC 12007 HCPCS outpatient 472 354 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 420.08 89 999999999 368.16 448.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_1 CDM 360 RC 12011 HCPCS outpatient 164.16 123.12 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 147.74 999999999 128.04 155.95 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_1 CDM 360 RC 12011 HCPCS outpatient 164.16 123.12 AETNA MCR ADV AETNA MCR ADV 128.04 78 999999999 128.04 155.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_1 CDM 360 RC 12011 HCPCS outpatient 164.16 123.12 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 143.75 87.57 999999999 128.04 155.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_1 CDM 360 RC 12011 HCPCS outpatient 164.16 123.12 COORDINATED CARE MCAID COORDINATED CARE MCAID 139.65 85.07 999999999 128.04 155.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_1 CDM 360 RC 12011 HCPCS outpatient 164.16 123.12 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 139.65 85.07 999999999 128.04 155.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_1 CDM 360 RC 12011 HCPCS outpatient 164.16 123.12 MOLINA MCAID MOLINA MCAID 136.91 83.4 999999999 128.04 155.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_1 CDM 360 RC 12011 HCPCS outpatient 164.16 123.12 MOLINA MCR ADV MOLINA MCR ADV 146.1 89 999999999 128.04 155.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_1 CDM 360 RC 12011 HCPCS outpatient 164.16 123.12 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 146.1 89 999999999 128.04 155.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_1 CDM 360 RC 12011 HCPCS outpatient 164.16 123.12 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 146.1 89 999999999 128.04 155.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_1 CDM 360 RC 12011 HCPCS outpatient 164.16 123.12 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 147.74 90 999999999 128.04 155.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_1 CDM 360 RC 12011 HCPCS outpatient 164.16 123.12 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 155.95 95 999999999 128.04 155.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_1 CDM 360 RC 12011 HCPCS outpatient 164.16 123.12 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 155.95 95 999999999 128.04 155.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_1 CDM 360 RC 12011 HCPCS outpatient 164.16 123.12 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 146.1 89 999999999 128.04 155.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_1 CDM 360 RC 12011 HCPCS outpatient 164.16 123.12 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 144.46 88 999999999 128.04 155.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_1 CDM 360 RC 12011 HCPCS outpatient 164.16 123.12 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 146.1 89 999999999 128.04 155.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_2 CDM 360 RC 12011 HCPCS outpatient 164.16 123.12 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 147.74 999999999 128.04 155.95 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_2 CDM 360 RC 12011 HCPCS outpatient 164.16 123.12 AETNA MCR ADV AETNA MCR ADV 128.04 78 999999999 128.04 155.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_2 CDM 360 RC 12011 HCPCS outpatient 164.16 123.12 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 143.75 87.57 999999999 128.04 155.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_2 CDM 360 RC 12011 HCPCS outpatient 164.16 123.12 COORDINATED CARE MCAID COORDINATED CARE MCAID 139.65 85.07 999999999 128.04 155.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_2 CDM 360 RC 12011 HCPCS outpatient 164.16 123.12 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 139.65 85.07 999999999 128.04 155.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_2 CDM 360 RC 12011 HCPCS outpatient 164.16 123.12 MOLINA MCAID MOLINA MCAID 136.91 83.4 999999999 128.04 155.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_2 CDM 360 RC 12011 HCPCS outpatient 164.16 123.12 MOLINA MCR ADV MOLINA MCR ADV 146.1 89 999999999 128.04 155.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_2 CDM 360 RC 12011 HCPCS outpatient 164.16 123.12 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 146.1 89 999999999 128.04 155.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_2 CDM 360 RC 12011 HCPCS outpatient 164.16 123.12 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 146.1 89 999999999 128.04 155.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_2 CDM 360 RC 12011 HCPCS outpatient 164.16 123.12 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 147.74 90 999999999 128.04 155.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_2 CDM 360 RC 12011 HCPCS outpatient 164.16 123.12 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 155.95 95 999999999 128.04 155.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_2 CDM 360 RC 12011 HCPCS outpatient 164.16 123.12 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 155.95 95 999999999 128.04 155.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_2 CDM 360 RC 12011 HCPCS outpatient 164.16 123.12 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 146.1 89 999999999 128.04 155.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_2 CDM 360 RC 12011 HCPCS outpatient 164.16 123.12 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 144.46 88 999999999 128.04 155.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_2 CDM 360 RC 12011 HCPCS outpatient 164.16 123.12 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 146.1 89 999999999 128.04 155.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_3 CDM 360 RC 12011 HCPCS outpatient 230 172.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 207 999999999 179.4 218.5 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_3 CDM 360 RC 12011 HCPCS outpatient 230 172.5 AETNA MCR ADV AETNA MCR ADV 179.4 78 999999999 179.4 218.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_3 CDM 360 RC 12011 HCPCS outpatient 230 172.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 201.41 87.57 999999999 179.4 218.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_3 CDM 360 RC 12011 HCPCS outpatient 230 172.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 195.66 85.07 999999999 179.4 218.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_3 CDM 360 RC 12011 HCPCS outpatient 230 172.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 195.66 85.07 999999999 179.4 218.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_3 CDM 360 RC 12011 HCPCS outpatient 230 172.5 MOLINA MCAID MOLINA MCAID 191.82 83.4 999999999 179.4 218.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_3 CDM 360 RC 12011 HCPCS outpatient 230 172.5 MOLINA MCR ADV MOLINA MCR ADV 204.7 89 999999999 179.4 218.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_3 CDM 360 RC 12011 HCPCS outpatient 230 172.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 204.7 89 999999999 179.4 218.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_3 CDM 360 RC 12011 HCPCS outpatient 230 172.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 204.7 89 999999999 179.4 218.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_3 CDM 360 RC 12011 HCPCS outpatient 230 172.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 207 90 999999999 179.4 218.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_3 CDM 360 RC 12011 HCPCS outpatient 230 172.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 218.5 95 999999999 179.4 218.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_3 CDM 360 RC 12011 HCPCS outpatient 230 172.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 218.5 95 999999999 179.4 218.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_3 CDM 360 RC 12011 HCPCS outpatient 230 172.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 204.7 89 999999999 179.4 218.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_3 CDM 360 RC 12011 HCPCS outpatient 230 172.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 202.4 88 999999999 179.4 218.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12011_3 CDM 360 RC 12011 HCPCS outpatient 230 172.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 204.7 89 999999999 179.4 218.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_1 CDM 360 RC 12013 HCPCS outpatient 172.56 129.42 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 155.3 999999999 134.6 163.93 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_1 CDM 360 RC 12013 HCPCS outpatient 172.56 129.42 AETNA MCR ADV AETNA MCR ADV 134.6 78 999999999 134.6 163.93 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_1 CDM 360 RC 12013 HCPCS outpatient 172.56 129.42 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 151.11 87.57 999999999 134.6 163.93 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_1 CDM 360 RC 12013 HCPCS outpatient 172.56 129.42 COORDINATED CARE MCAID COORDINATED CARE MCAID 146.8 85.07 999999999 134.6 163.93 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_1 CDM 360 RC 12013 HCPCS outpatient 172.56 129.42 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 146.8 85.07 999999999 134.6 163.93 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_1 CDM 360 RC 12013 HCPCS outpatient 172.56 129.42 MOLINA MCAID MOLINA MCAID 143.92 83.4 999999999 134.6 163.93 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_1 CDM 360 RC 12013 HCPCS outpatient 172.56 129.42 MOLINA MCR ADV MOLINA MCR ADV 153.58 89 999999999 134.6 163.93 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_1 CDM 360 RC 12013 HCPCS outpatient 172.56 129.42 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 153.58 89 999999999 134.6 163.93 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_1 CDM 360 RC 12013 HCPCS outpatient 172.56 129.42 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 153.58 89 999999999 134.6 163.93 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_1 CDM 360 RC 12013 HCPCS outpatient 172.56 129.42 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 155.3 90 999999999 134.6 163.93 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_1 CDM 360 RC 12013 HCPCS outpatient 172.56 129.42 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 163.93 95 999999999 134.6 163.93 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_1 CDM 360 RC 12013 HCPCS outpatient 172.56 129.42 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 163.93 95 999999999 134.6 163.93 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_1 CDM 360 RC 12013 HCPCS outpatient 172.56 129.42 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 153.58 89 999999999 134.6 163.93 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_1 CDM 360 RC 12013 HCPCS outpatient 172.56 129.42 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 151.85 88 999999999 134.6 163.93 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_1 CDM 360 RC 12013 HCPCS outpatient 172.56 129.42 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 153.58 89 999999999 134.6 163.93 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_2 CDM 360 RC 12013 HCPCS outpatient 172.56 129.42 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 155.3 999999999 134.6 163.93 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_2 CDM 360 RC 12013 HCPCS outpatient 172.56 129.42 AETNA MCR ADV AETNA MCR ADV 134.6 78 999999999 134.6 163.93 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_2 CDM 360 RC 12013 HCPCS outpatient 172.56 129.42 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 151.11 87.57 999999999 134.6 163.93 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_2 CDM 360 RC 12013 HCPCS outpatient 172.56 129.42 COORDINATED CARE MCAID COORDINATED CARE MCAID 146.8 85.07 999999999 134.6 163.93 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_2 CDM 360 RC 12013 HCPCS outpatient 172.56 129.42 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 146.8 85.07 999999999 134.6 163.93 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_2 CDM 360 RC 12013 HCPCS outpatient 172.56 129.42 MOLINA MCAID MOLINA MCAID 143.92 83.4 999999999 134.6 163.93 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_2 CDM 360 RC 12013 HCPCS outpatient 172.56 129.42 MOLINA MCR ADV MOLINA MCR ADV 153.58 89 999999999 134.6 163.93 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_2 CDM 360 RC 12013 HCPCS outpatient 172.56 129.42 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 153.58 89 999999999 134.6 163.93 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_2 CDM 360 RC 12013 HCPCS outpatient 172.56 129.42 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 153.58 89 999999999 134.6 163.93 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_2 CDM 360 RC 12013 HCPCS outpatient 172.56 129.42 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 155.3 90 999999999 134.6 163.93 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_2 CDM 360 RC 12013 HCPCS outpatient 172.56 129.42 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 163.93 95 999999999 134.6 163.93 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_2 CDM 360 RC 12013 HCPCS outpatient 172.56 129.42 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 163.93 95 999999999 134.6 163.93 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_2 CDM 360 RC 12013 HCPCS outpatient 172.56 129.42 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 153.58 89 999999999 134.6 163.93 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_2 CDM 360 RC 12013 HCPCS outpatient 172.56 129.42 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 151.85 88 999999999 134.6 163.93 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_2 CDM 360 RC 12013 HCPCS outpatient 172.56 129.42 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 153.58 89 999999999 134.6 163.93 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_3 CDM 360 RC 12013 HCPCS outpatient 239 179.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 215.1 999999999 186.42 227.05 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_3 CDM 360 RC 12013 HCPCS outpatient 239 179.25 AETNA MCR ADV AETNA MCR ADV 186.42 78 999999999 186.42 227.05 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_3 CDM 360 RC 12013 HCPCS outpatient 239 179.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 209.29 87.57 999999999 186.42 227.05 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_3 CDM 360 RC 12013 HCPCS outpatient 239 179.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 203.32 85.07 999999999 186.42 227.05 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_3 CDM 360 RC 12013 HCPCS outpatient 239 179.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 203.32 85.07 999999999 186.42 227.05 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_3 CDM 360 RC 12013 HCPCS outpatient 239 179.25 MOLINA MCAID MOLINA MCAID 199.33 83.4 999999999 186.42 227.05 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_3 CDM 360 RC 12013 HCPCS outpatient 239 179.25 MOLINA MCR ADV MOLINA MCR ADV 212.71 89 999999999 186.42 227.05 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_3 CDM 360 RC 12013 HCPCS outpatient 239 179.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 212.71 89 999999999 186.42 227.05 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_3 CDM 360 RC 12013 HCPCS outpatient 239 179.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 212.71 89 999999999 186.42 227.05 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_3 CDM 360 RC 12013 HCPCS outpatient 239 179.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 215.1 90 999999999 186.42 227.05 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_3 CDM 360 RC 12013 HCPCS outpatient 239 179.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 227.05 95 999999999 186.42 227.05 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_3 CDM 360 RC 12013 HCPCS outpatient 239 179.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 227.05 95 999999999 186.42 227.05 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_3 CDM 360 RC 12013 HCPCS outpatient 239 179.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 212.71 89 999999999 186.42 227.05 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_3 CDM 360 RC 12013 HCPCS outpatient 239 179.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 210.32 88 999999999 186.42 227.05 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12013_3 CDM 360 RC 12013 HCPCS outpatient 239 179.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 212.71 89 999999999 186.42 227.05 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12014_1 CDM 360 RC 12014 HCPCS outpatient 221.67 166.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 199.5 999999999 172.9 210.59 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12014_1 CDM 360 RC 12014 HCPCS outpatient 221.67 166.25 AETNA MCR ADV AETNA MCR ADV 172.9 78 999999999 172.9 210.59 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12014_1 CDM 360 RC 12014 HCPCS outpatient 221.67 166.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 194.12 87.57 999999999 172.9 210.59 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12014_1 CDM 360 RC 12014 HCPCS outpatient 221.67 166.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 188.57 85.07 999999999 172.9 210.59 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12014_1 CDM 360 RC 12014 HCPCS outpatient 221.67 166.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 188.57 85.07 999999999 172.9 210.59 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12014_1 CDM 360 RC 12014 HCPCS outpatient 221.67 166.25 MOLINA MCAID MOLINA MCAID 184.87 83.4 999999999 172.9 210.59 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12014_1 CDM 360 RC 12014 HCPCS outpatient 221.67 166.25 MOLINA MCR ADV MOLINA MCR ADV 197.29 89 999999999 172.9 210.59 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12014_1 CDM 360 RC 12014 HCPCS outpatient 221.67 166.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 197.29 89 999999999 172.9 210.59 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12014_1 CDM 360 RC 12014 HCPCS outpatient 221.67 166.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 197.29 89 999999999 172.9 210.59 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12014_1 CDM 360 RC 12014 HCPCS outpatient 221.67 166.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 199.5 90 999999999 172.9 210.59 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12014_1 CDM 360 RC 12014 HCPCS outpatient 221.67 166.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 210.59 95 999999999 172.9 210.59 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12014_1 CDM 360 RC 12014 HCPCS outpatient 221.67 166.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 210.59 95 999999999 172.9 210.59 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12014_1 CDM 360 RC 12014 HCPCS outpatient 221.67 166.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 197.29 89 999999999 172.9 210.59 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12014_1 CDM 360 RC 12014 HCPCS outpatient 221.67 166.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 195.07 88 999999999 172.9 210.59 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12014_1 CDM 360 RC 12014 HCPCS outpatient 221.67 166.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 197.29 89 999999999 172.9 210.59 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12014_3 CDM 360 RC 12014 HCPCS outpatient 292 219 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 262.8 999999999 227.76 277.4 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12014_3 CDM 360 RC 12014 HCPCS outpatient 292 219 AETNA MCR ADV AETNA MCR ADV 227.76 78 999999999 227.76 277.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12014_3 CDM 360 RC 12014 HCPCS outpatient 292 219 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 255.7 87.57 999999999 227.76 277.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12014_3 CDM 360 RC 12014 HCPCS outpatient 292 219 COORDINATED CARE MCAID COORDINATED CARE MCAID 248.4 85.07 999999999 227.76 277.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12014_3 CDM 360 RC 12014 HCPCS outpatient 292 219 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 248.4 85.07 999999999 227.76 277.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12014_3 CDM 360 RC 12014 HCPCS outpatient 292 219 MOLINA MCAID MOLINA MCAID 243.53 83.4 999999999 227.76 277.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12014_3 CDM 360 RC 12014 HCPCS outpatient 292 219 MOLINA MCR ADV MOLINA MCR ADV 259.88 89 999999999 227.76 277.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12014_3 CDM 360 RC 12014 HCPCS outpatient 292 219 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 259.88 89 999999999 227.76 277.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12014_3 CDM 360 RC 12014 HCPCS outpatient 292 219 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 259.88 89 999999999 227.76 277.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12014_3 CDM 360 RC 12014 HCPCS outpatient 292 219 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 262.8 90 999999999 227.76 277.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12014_3 CDM 360 RC 12014 HCPCS outpatient 292 219 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 277.4 95 999999999 227.76 277.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12014_3 CDM 360 RC 12014 HCPCS outpatient 292 219 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 277.4 95 999999999 227.76 277.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12014_3 CDM 360 RC 12014 HCPCS outpatient 292 219 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 259.88 89 999999999 227.76 277.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12014_3 CDM 360 RC 12014 HCPCS outpatient 292 219 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 256.96 88 999999999 227.76 277.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12014_3 CDM 360 RC 12014 HCPCS outpatient 292 219 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 259.88 89 999999999 227.76 277.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12015_1 CDM 360 RC 12015 HCPCS outpatient 279.9 209.93 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 251.91 999999999 218.32 265.91 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12015_1 CDM 360 RC 12015 HCPCS outpatient 279.9 209.93 AETNA MCR ADV AETNA MCR ADV 218.32 78 999999999 218.32 265.91 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12015_1 CDM 360 RC 12015 HCPCS outpatient 279.9 209.93 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 245.11 87.57 999999999 218.32 265.91 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12015_1 CDM 360 RC 12015 HCPCS outpatient 279.9 209.93 COORDINATED CARE MCAID COORDINATED CARE MCAID 238.11 85.07 999999999 218.32 265.91 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12015_1 CDM 360 RC 12015 HCPCS outpatient 279.9 209.93 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 238.11 85.07 999999999 218.32 265.91 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12015_1 CDM 360 RC 12015 HCPCS outpatient 279.9 209.93 MOLINA MCAID MOLINA MCAID 233.44 83.4 999999999 218.32 265.91 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12015_1 CDM 360 RC 12015 HCPCS outpatient 279.9 209.93 MOLINA MCR ADV MOLINA MCR ADV 249.11 89 999999999 218.32 265.91 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12015_1 CDM 360 RC 12015 HCPCS outpatient 279.9 209.93 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 249.11 89 999999999 218.32 265.91 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12015_1 CDM 360 RC 12015 HCPCS outpatient 279.9 209.93 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 249.11 89 999999999 218.32 265.91 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12015_1 CDM 360 RC 12015 HCPCS outpatient 279.9 209.93 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 251.91 90 999999999 218.32 265.91 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12015_1 CDM 360 RC 12015 HCPCS outpatient 279.9 209.93 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 265.91 95 999999999 218.32 265.91 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12015_1 CDM 360 RC 12015 HCPCS outpatient 279.9 209.93 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 265.91 95 999999999 218.32 265.91 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12015_1 CDM 360 RC 12015 HCPCS outpatient 279.9 209.93 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 249.11 89 999999999 218.32 265.91 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12015_1 CDM 360 RC 12015 HCPCS outpatient 279.9 209.93 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 246.31 88 999999999 218.32 265.91 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12015_1 CDM 360 RC 12015 HCPCS outpatient 279.9 209.93 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 249.11 89 999999999 218.32 265.91 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12015_3 CDM 360 RC 12015 HCPCS outpatient 350 262.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 315 999999999 273 332.5 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12015_3 CDM 360 RC 12015 HCPCS outpatient 350 262.5 AETNA MCR ADV AETNA MCR ADV 273 78 999999999 273 332.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12015_3 CDM 360 RC 12015 HCPCS outpatient 350 262.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 306.5 87.57 999999999 273 332.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12015_3 CDM 360 RC 12015 HCPCS outpatient 350 262.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 297.75 85.07 999999999 273 332.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12015_3 CDM 360 RC 12015 HCPCS outpatient 350 262.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 297.75 85.07 999999999 273 332.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12015_3 CDM 360 RC 12015 HCPCS outpatient 350 262.5 MOLINA MCAID MOLINA MCAID 291.9 83.4 999999999 273 332.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12015_3 CDM 360 RC 12015 HCPCS outpatient 350 262.5 MOLINA MCR ADV MOLINA MCR ADV 311.5 89 999999999 273 332.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12015_3 CDM 360 RC 12015 HCPCS outpatient 350 262.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 311.5 89 999999999 273 332.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12015_3 CDM 360 RC 12015 HCPCS outpatient 350 262.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 311.5 89 999999999 273 332.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12015_3 CDM 360 RC 12015 HCPCS outpatient 350 262.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 315 90 999999999 273 332.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12015_3 CDM 360 RC 12015 HCPCS outpatient 350 262.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 332.5 95 999999999 273 332.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12015_3 CDM 360 RC 12015 HCPCS outpatient 350 262.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 332.5 95 999999999 273 332.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12015_3 CDM 360 RC 12015 HCPCS outpatient 350 262.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 311.5 89 999999999 273 332.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12015_3 CDM 360 RC 12015 HCPCS outpatient 350 262.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 308 88 999999999 273 332.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12015_3 CDM 360 RC 12015 HCPCS outpatient 350 262.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 311.5 89 999999999 273 332.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12016_1 CDM 360 RC 12016 HCPCS outpatient 382.62 286.97 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 344.36 999999999 298.44 363.49 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12016_1 CDM 360 RC 12016 HCPCS outpatient 382.62 286.97 AETNA MCR ADV AETNA MCR ADV 298.44 78 999999999 298.44 363.49 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12016_1 CDM 360 RC 12016 HCPCS outpatient 382.62 286.97 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 335.06 87.57 999999999 298.44 363.49 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12016_1 CDM 360 RC 12016 HCPCS outpatient 382.62 286.97 COORDINATED CARE MCAID COORDINATED CARE MCAID 325.49 85.07 999999999 298.44 363.49 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12016_1 CDM 360 RC 12016 HCPCS outpatient 382.62 286.97 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 325.49 85.07 999999999 298.44 363.49 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12016_1 CDM 360 RC 12016 HCPCS outpatient 382.62 286.97 MOLINA MCAID MOLINA MCAID 319.11 83.4 999999999 298.44 363.49 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12016_1 CDM 360 RC 12016 HCPCS outpatient 382.62 286.97 MOLINA MCR ADV MOLINA MCR ADV 340.53 89 999999999 298.44 363.49 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12016_1 CDM 360 RC 12016 HCPCS outpatient 382.62 286.97 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 340.53 89 999999999 298.44 363.49 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12016_1 CDM 360 RC 12016 HCPCS outpatient 382.62 286.97 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 340.53 89 999999999 298.44 363.49 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12016_1 CDM 360 RC 12016 HCPCS outpatient 382.62 286.97 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 344.36 90 999999999 298.44 363.49 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12016_1 CDM 360 RC 12016 HCPCS outpatient 382.62 286.97 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 363.49 95 999999999 298.44 363.49 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12016_1 CDM 360 RC 12016 HCPCS outpatient 382.62 286.97 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 363.49 95 999999999 298.44 363.49 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12016_1 CDM 360 RC 12016 HCPCS outpatient 382.62 286.97 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 340.53 89 999999999 298.44 363.49 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12016_1 CDM 360 RC 12016 HCPCS outpatient 382.62 286.97 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 336.71 88 999999999 298.44 363.49 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12016_1 CDM 360 RC 12016 HCPCS outpatient 382.62 286.97 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 340.53 89 999999999 298.44 363.49 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12016_3 CDM 360 RC 12016 HCPCS outpatient 450 337.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 405 999999999 351 427.5 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12016_3 CDM 360 RC 12016 HCPCS outpatient 450 337.5 AETNA MCR ADV AETNA MCR ADV 351 78 999999999 351 427.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12016_3 CDM 360 RC 12016 HCPCS outpatient 450 337.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 394.07 87.57 999999999 351 427.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12016_3 CDM 360 RC 12016 HCPCS outpatient 450 337.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 382.82 85.07 999999999 351 427.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12016_3 CDM 360 RC 12016 HCPCS outpatient 450 337.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 382.82 85.07 999999999 351 427.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12016_3 CDM 360 RC 12016 HCPCS outpatient 450 337.5 MOLINA MCAID MOLINA MCAID 375.3 83.4 999999999 351 427.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12016_3 CDM 360 RC 12016 HCPCS outpatient 450 337.5 MOLINA MCR ADV MOLINA MCR ADV 400.5 89 999999999 351 427.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12016_3 CDM 360 RC 12016 HCPCS outpatient 450 337.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 400.5 89 999999999 351 427.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12016_3 CDM 360 RC 12016 HCPCS outpatient 450 337.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 400.5 89 999999999 351 427.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12016_3 CDM 360 RC 12016 HCPCS outpatient 450 337.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 405 90 999999999 351 427.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12016_3 CDM 360 RC 12016 HCPCS outpatient 450 337.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 427.5 95 999999999 351 427.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12016_3 CDM 360 RC 12016 HCPCS outpatient 450 337.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 427.5 95 999999999 351 427.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12016_3 CDM 360 RC 12016 HCPCS outpatient 450 337.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 400.5 89 999999999 351 427.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12016_3 CDM 360 RC 12016 HCPCS outpatient 450 337.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 396 88 999999999 351 427.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12016_3 CDM 360 RC 12016 HCPCS outpatient 450 337.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 400.5 89 999999999 351 427.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12017_1 CDM 360 RC 12017 HCPCS outpatient 451.65 338.74 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 406.49 999999999 352.29 429.07 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12017_1 CDM 360 RC 12017 HCPCS outpatient 451.65 338.74 AETNA MCR ADV AETNA MCR ADV 352.29 78 999999999 352.29 429.07 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12017_1 CDM 360 RC 12017 HCPCS outpatient 451.65 338.74 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 395.51 87.57 999999999 352.29 429.07 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12017_1 CDM 360 RC 12017 HCPCS outpatient 451.65 338.74 COORDINATED CARE MCAID COORDINATED CARE MCAID 384.22 85.07 999999999 352.29 429.07 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12017_1 CDM 360 RC 12017 HCPCS outpatient 451.65 338.74 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 384.22 85.07 999999999 352.29 429.07 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12017_1 CDM 360 RC 12017 HCPCS outpatient 451.65 338.74 MOLINA MCAID MOLINA MCAID 376.68 83.4 999999999 352.29 429.07 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12017_1 CDM 360 RC 12017 HCPCS outpatient 451.65 338.74 MOLINA MCR ADV MOLINA MCR ADV 401.97 89 999999999 352.29 429.07 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12017_1 CDM 360 RC 12017 HCPCS outpatient 451.65 338.74 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 401.97 89 999999999 352.29 429.07 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12017_1 CDM 360 RC 12017 HCPCS outpatient 451.65 338.74 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 401.97 89 999999999 352.29 429.07 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12017_1 CDM 360 RC 12017 HCPCS outpatient 451.65 338.74 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 406.49 90 999999999 352.29 429.07 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12017_1 CDM 360 RC 12017 HCPCS outpatient 451.65 338.74 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 429.07 95 999999999 352.29 429.07 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12017_1 CDM 360 RC 12017 HCPCS outpatient 451.65 338.74 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 429.07 95 999999999 352.29 429.07 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12017_1 CDM 360 RC 12017 HCPCS outpatient 451.65 338.74 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 401.97 89 999999999 352.29 429.07 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12017_1 CDM 360 RC 12017 HCPCS outpatient 451.65 338.74 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 397.45 88 999999999 352.29 429.07 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12017_1 CDM 360 RC 12017 HCPCS outpatient 451.65 338.74 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 401.97 89 999999999 352.29 429.07 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12017_3 CDM 360 RC 12017 HCPCS outpatient 300 225 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 270 999999999 234 285 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12017_3 CDM 360 RC 12017 HCPCS outpatient 300 225 AETNA MCR ADV AETNA MCR ADV 234 78 999999999 234 285 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12017_3 CDM 360 RC 12017 HCPCS outpatient 300 225 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 262.71 87.57 999999999 234 285 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12017_3 CDM 360 RC 12017 HCPCS outpatient 300 225 COORDINATED CARE MCAID COORDINATED CARE MCAID 255.21 85.07 999999999 234 285 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12017_3 CDM 360 RC 12017 HCPCS outpatient 300 225 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 255.21 85.07 999999999 234 285 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12017_3 CDM 360 RC 12017 HCPCS outpatient 300 225 MOLINA MCAID MOLINA MCAID 250.2 83.4 999999999 234 285 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12017_3 CDM 360 RC 12017 HCPCS outpatient 300 225 MOLINA MCR ADV MOLINA MCR ADV 267 89 999999999 234 285 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12017_3 CDM 360 RC 12017 HCPCS outpatient 300 225 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 267 89 999999999 234 285 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12017_3 CDM 360 RC 12017 HCPCS outpatient 300 225 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 267 89 999999999 234 285 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12017_3 CDM 360 RC 12017 HCPCS outpatient 300 225 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 270 90 999999999 234 285 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12017_3 CDM 360 RC 12017 HCPCS outpatient 300 225 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 285 95 999999999 234 285 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12017_3 CDM 360 RC 12017 HCPCS outpatient 300 225 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 285 95 999999999 234 285 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12017_3 CDM 360 RC 12017 HCPCS outpatient 300 225 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 267 89 999999999 234 285 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12017_3 CDM 360 RC 12017 HCPCS outpatient 300 225 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 264 88 999999999 234 285 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12017_3 CDM 360 RC 12017 HCPCS outpatient 300 225 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 267 89 999999999 234 285 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 12018_1 CDM 360 RC 12018 HCPCS outpatient 282 211.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 253.8 999999999 219.96 267.9 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 12018_1 CDM 360 RC 12018 HCPCS outpatient 282 211.5 AETNA MCR ADV AETNA MCR ADV 219.96 78 999999999 219.96 267.9 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 12018_1 CDM 360 RC 12018 HCPCS outpatient 282 211.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 246.95 87.57 999999999 219.96 267.9 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 12018_1 CDM 360 RC 12018 HCPCS outpatient 282 211.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 239.9 85.07 999999999 219.96 267.9 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 12018_1 CDM 360 RC 12018 HCPCS outpatient 282 211.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 239.9 85.07 999999999 219.96 267.9 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 12018_1 CDM 360 RC 12018 HCPCS outpatient 282 211.5 MOLINA MCAID MOLINA MCAID 235.19 83.4 999999999 219.96 267.9 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 12018_1 CDM 360 RC 12018 HCPCS outpatient 282 211.5 MOLINA MCR ADV MOLINA MCR ADV 250.98 89 999999999 219.96 267.9 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 12018_1 CDM 360 RC 12018 HCPCS outpatient 282 211.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 250.98 89 999999999 219.96 267.9 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 12018_1 CDM 360 RC 12018 HCPCS outpatient 282 211.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 250.98 89 999999999 219.96 267.9 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 12018_1 CDM 360 RC 12018 HCPCS outpatient 282 211.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 253.8 90 999999999 219.96 267.9 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 12018_1 CDM 360 RC 12018 HCPCS outpatient 282 211.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 267.9 95 999999999 219.96 267.9 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 12018_1 CDM 360 RC 12018 HCPCS outpatient 282 211.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 267.9 95 999999999 219.96 267.9 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 12018_1 CDM 360 RC 12018 HCPCS outpatient 282 211.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 250.98 89 999999999 219.96 267.9 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 12018_1 CDM 360 RC 12018 HCPCS outpatient 282 211.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 248.16 88 999999999 219.96 267.9 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 12018_1 CDM 360 RC 12018 HCPCS outpatient 282 211.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 250.98 89 999999999 219.96 267.9 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 12018_3 CDM 360 RC 12018 HCPCS outpatient 340 255 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 306 999999999 265.2 323 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 12018_3 CDM 360 RC 12018 HCPCS outpatient 340 255 AETNA MCR ADV AETNA MCR ADV 265.2 78 999999999 265.2 323 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 12018_3 CDM 360 RC 12018 HCPCS outpatient 340 255 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 297.74 87.57 999999999 265.2 323 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 12018_3 CDM 360 RC 12018 HCPCS outpatient 340 255 COORDINATED CARE MCAID COORDINATED CARE MCAID 289.24 85.07 999999999 265.2 323 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 12018_3 CDM 360 RC 12018 HCPCS outpatient 340 255 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 289.24 85.07 999999999 265.2 323 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 12018_3 CDM 360 RC 12018 HCPCS outpatient 340 255 MOLINA MCAID MOLINA MCAID 283.56 83.4 999999999 265.2 323 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 12018_3 CDM 360 RC 12018 HCPCS outpatient 340 255 MOLINA MCR ADV MOLINA MCR ADV 302.6 89 999999999 265.2 323 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 12018_3 CDM 360 RC 12018 HCPCS outpatient 340 255 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 302.6 89 999999999 265.2 323 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 12018_3 CDM 360 RC 12018 HCPCS outpatient 340 255 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 302.6 89 999999999 265.2 323 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 12018_3 CDM 360 RC 12018 HCPCS outpatient 340 255 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 306 90 999999999 265.2 323 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 12018_3 CDM 360 RC 12018 HCPCS outpatient 340 255 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 323 95 999999999 265.2 323 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 12018_3 CDM 360 RC 12018 HCPCS outpatient 340 255 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 323 95 999999999 265.2 323 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 12018_3 CDM 360 RC 12018 HCPCS outpatient 340 255 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 302.6 89 999999999 265.2 323 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 12018_3 CDM 360 RC 12018 HCPCS outpatient 340 255 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 299.2 88 999999999 265.2 323 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 12018_3 CDM 360 RC 12018 HCPCS outpatient 340 255 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 302.6 89 999999999 265.2 323 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE 12020_1 CDM 360 RC 12020 HCPCS outpatient 511 383.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 459.9 999999999 398.58 485.45 case rate TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE 12020_1 CDM 360 RC 12020 HCPCS outpatient 511 383.25 AETNA MCR ADV AETNA MCR ADV 398.58 78 999999999 398.58 485.45 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE 12020_1 CDM 360 RC 12020 HCPCS outpatient 511 383.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 447.48 87.57 999999999 398.58 485.45 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE 12020_1 CDM 360 RC 12020 HCPCS outpatient 511 383.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 434.71 85.07 999999999 398.58 485.45 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE 12020_1 CDM 360 RC 12020 HCPCS outpatient 511 383.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 434.71 85.07 999999999 398.58 485.45 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE 12020_1 CDM 360 RC 12020 HCPCS outpatient 511 383.25 MOLINA MCAID MOLINA MCAID 426.17 83.4 999999999 398.58 485.45 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE 12020_1 CDM 360 RC 12020 HCPCS outpatient 511 383.25 MOLINA MCR ADV MOLINA MCR ADV 454.79 89 999999999 398.58 485.45 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE 12020_1 CDM 360 RC 12020 HCPCS outpatient 511 383.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 454.79 89 999999999 398.58 485.45 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE 12020_1 CDM 360 RC 12020 HCPCS outpatient 511 383.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 454.79 89 999999999 398.58 485.45 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE 12020_1 CDM 360 RC 12020 HCPCS outpatient 511 383.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 459.9 90 999999999 398.58 485.45 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE 12020_1 CDM 360 RC 12020 HCPCS outpatient 511 383.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 485.45 95 999999999 398.58 485.45 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE 12020_1 CDM 360 RC 12020 HCPCS outpatient 511 383.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 485.45 95 999999999 398.58 485.45 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE 12020_1 CDM 360 RC 12020 HCPCS outpatient 511 383.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 454.79 89 999999999 398.58 485.45 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE 12020_1 CDM 360 RC 12020 HCPCS outpatient 511 383.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 449.68 88 999999999 398.58 485.45 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE 12020_1 CDM 360 RC 12020 HCPCS outpatient 511 383.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 454.79 89 999999999 398.58 485.45 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 12021_1 CDM 360 RC 12021 HCPCS outpatient 425.43 319.07 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 382.89 999999999 331.84 404.16 case rate TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 12021_1 CDM 360 RC 12021 HCPCS outpatient 425.43 319.07 AETNA MCR ADV AETNA MCR ADV 331.84 78 999999999 331.84 404.16 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 12021_1 CDM 360 RC 12021 HCPCS outpatient 425.43 319.07 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 372.55 87.57 999999999 331.84 404.16 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 12021_1 CDM 360 RC 12021 HCPCS outpatient 425.43 319.07 COORDINATED CARE MCAID COORDINATED CARE MCAID 361.91 85.07 999999999 331.84 404.16 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 12021_1 CDM 360 RC 12021 HCPCS outpatient 425.43 319.07 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 361.91 85.07 999999999 331.84 404.16 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 12021_1 CDM 360 RC 12021 HCPCS outpatient 425.43 319.07 MOLINA MCAID MOLINA MCAID 354.81 83.4 999999999 331.84 404.16 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 12021_1 CDM 360 RC 12021 HCPCS outpatient 425.43 319.07 MOLINA MCR ADV MOLINA MCR ADV 378.63 89 999999999 331.84 404.16 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 12021_1 CDM 360 RC 12021 HCPCS outpatient 425.43 319.07 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 378.63 89 999999999 331.84 404.16 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 12021_1 CDM 360 RC 12021 HCPCS outpatient 425.43 319.07 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 378.63 89 999999999 331.84 404.16 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 12021_1 CDM 360 RC 12021 HCPCS outpatient 425.43 319.07 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 382.89 90 999999999 331.84 404.16 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 12021_1 CDM 360 RC 12021 HCPCS outpatient 425.43 319.07 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 404.16 95 999999999 331.84 404.16 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 12021_1 CDM 360 RC 12021 HCPCS outpatient 425.43 319.07 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 404.16 95 999999999 331.84 404.16 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 12021_1 CDM 360 RC 12021 HCPCS outpatient 425.43 319.07 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 378.63 89 999999999 331.84 404.16 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 12021_1 CDM 360 RC 12021 HCPCS outpatient 425.43 319.07 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 374.38 88 999999999 331.84 404.16 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 12021_1 CDM 360 RC 12021 HCPCS outpatient 425.43 319.07 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 378.63 89 999999999 331.84 404.16 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12031_1 CDM 360 RC 12031 HCPCS outpatient 455.4 341.55 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 409.86 999999999 355.21 432.63 case rate "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12031_1 CDM 360 RC 12031 HCPCS outpatient 455.4 341.55 AETNA MCR ADV AETNA MCR ADV 355.21 78 999999999 355.21 432.63 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12031_1 CDM 360 RC 12031 HCPCS outpatient 455.4 341.55 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 398.79 87.57 999999999 355.21 432.63 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12031_1 CDM 360 RC 12031 HCPCS outpatient 455.4 341.55 COORDINATED CARE MCAID COORDINATED CARE MCAID 387.41 85.07 999999999 355.21 432.63 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12031_1 CDM 360 RC 12031 HCPCS outpatient 455.4 341.55 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 387.41 85.07 999999999 355.21 432.63 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12031_1 CDM 360 RC 12031 HCPCS outpatient 455.4 341.55 MOLINA MCAID MOLINA MCAID 379.8 83.4 999999999 355.21 432.63 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12031_1 CDM 360 RC 12031 HCPCS outpatient 455.4 341.55 MOLINA MCR ADV MOLINA MCR ADV 405.31 89 999999999 355.21 432.63 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12031_1 CDM 360 RC 12031 HCPCS outpatient 455.4 341.55 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 405.31 89 999999999 355.21 432.63 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12031_1 CDM 360 RC 12031 HCPCS outpatient 455.4 341.55 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 405.31 89 999999999 355.21 432.63 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12031_1 CDM 360 RC 12031 HCPCS outpatient 455.4 341.55 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 409.86 90 999999999 355.21 432.63 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12031_1 CDM 360 RC 12031 HCPCS outpatient 455.4 341.55 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 432.63 95 999999999 355.21 432.63 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12031_1 CDM 360 RC 12031 HCPCS outpatient 455.4 341.55 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 432.63 95 999999999 355.21 432.63 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12031_1 CDM 360 RC 12031 HCPCS outpatient 455.4 341.55 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 405.31 89 999999999 355.21 432.63 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12031_1 CDM 360 RC 12031 HCPCS outpatient 455.4 341.55 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 400.75 88 999999999 355.21 432.63 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12031_1 CDM 360 RC 12031 HCPCS outpatient 455.4 341.55 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 405.31 89 999999999 355.21 432.63 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12031_3 CDM 360 RC 12031 HCPCS outpatient 548 411 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 493.2 999999999 427.44 520.6 case rate "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12031_3 CDM 360 RC 12031 HCPCS outpatient 548 411 AETNA MCR ADV AETNA MCR ADV 427.44 78 999999999 427.44 520.6 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12031_3 CDM 360 RC 12031 HCPCS outpatient 548 411 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 479.88 87.57 999999999 427.44 520.6 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12031_3 CDM 360 RC 12031 HCPCS outpatient 548 411 COORDINATED CARE MCAID COORDINATED CARE MCAID 466.18 85.07 999999999 427.44 520.6 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12031_3 CDM 360 RC 12031 HCPCS outpatient 548 411 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 466.18 85.07 999999999 427.44 520.6 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12031_3 CDM 360 RC 12031 HCPCS outpatient 548 411 MOLINA MCAID MOLINA MCAID 457.03 83.4 999999999 427.44 520.6 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12031_3 CDM 360 RC 12031 HCPCS outpatient 548 411 MOLINA MCR ADV MOLINA MCR ADV 487.72 89 999999999 427.44 520.6 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12031_3 CDM 360 RC 12031 HCPCS outpatient 548 411 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 487.72 89 999999999 427.44 520.6 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12031_3 CDM 360 RC 12031 HCPCS outpatient 548 411 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 487.72 89 999999999 427.44 520.6 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12031_3 CDM 360 RC 12031 HCPCS outpatient 548 411 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 493.2 90 999999999 427.44 520.6 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12031_3 CDM 360 RC 12031 HCPCS outpatient 548 411 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 520.6 95 999999999 427.44 520.6 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12031_3 CDM 360 RC 12031 HCPCS outpatient 548 411 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 520.6 95 999999999 427.44 520.6 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12031_3 CDM 360 RC 12031 HCPCS outpatient 548 411 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 487.72 89 999999999 427.44 520.6 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12031_3 CDM 360 RC 12031 HCPCS outpatient 548 411 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 482.24 88 999999999 427.44 520.6 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS" 12031_3 CDM 360 RC 12031 HCPCS outpatient 548 411 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 487.72 89 999999999 427.44 520.6 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_1 CDM 360 RC 12032 HCPCS outpatient 569.88 427.41 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 512.89 999999999 444.51 541.39 case rate "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_1 CDM 360 RC 12032 HCPCS outpatient 569.88 427.41 AETNA MCR ADV AETNA MCR ADV 444.51 78 999999999 444.51 541.39 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_1 CDM 360 RC 12032 HCPCS outpatient 569.88 427.41 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 499.04 87.57 999999999 444.51 541.39 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_1 CDM 360 RC 12032 HCPCS outpatient 569.88 427.41 COORDINATED CARE MCAID COORDINATED CARE MCAID 484.8 85.07 999999999 444.51 541.39 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_1 CDM 360 RC 12032 HCPCS outpatient 569.88 427.41 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 484.8 85.07 999999999 444.51 541.39 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_1 CDM 360 RC 12032 HCPCS outpatient 569.88 427.41 MOLINA MCAID MOLINA MCAID 475.28 83.4 999999999 444.51 541.39 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_1 CDM 360 RC 12032 HCPCS outpatient 569.88 427.41 MOLINA MCR ADV MOLINA MCR ADV 507.19 89 999999999 444.51 541.39 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_1 CDM 360 RC 12032 HCPCS outpatient 569.88 427.41 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 507.19 89 999999999 444.51 541.39 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_1 CDM 360 RC 12032 HCPCS outpatient 569.88 427.41 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 507.19 89 999999999 444.51 541.39 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_1 CDM 360 RC 12032 HCPCS outpatient 569.88 427.41 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 512.89 90 999999999 444.51 541.39 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_1 CDM 360 RC 12032 HCPCS outpatient 569.88 427.41 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 541.39 95 999999999 444.51 541.39 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_1 CDM 360 RC 12032 HCPCS outpatient 569.88 427.41 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 541.39 95 999999999 444.51 541.39 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_1 CDM 360 RC 12032 HCPCS outpatient 569.88 427.41 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 507.19 89 999999999 444.51 541.39 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_1 CDM 360 RC 12032 HCPCS outpatient 569.88 427.41 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 501.49 88 999999999 444.51 541.39 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_1 CDM 360 RC 12032 HCPCS outpatient 569.88 427.41 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 507.19 89 999999999 444.51 541.39 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_2 CDM 360 RC 12032 HCPCS outpatient 569.88 427.41 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 512.89 999999999 444.51 541.39 case rate "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_2 CDM 360 RC 12032 HCPCS outpatient 569.88 427.41 AETNA MCR ADV AETNA MCR ADV 444.51 78 999999999 444.51 541.39 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_2 CDM 360 RC 12032 HCPCS outpatient 569.88 427.41 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 499.04 87.57 999999999 444.51 541.39 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_2 CDM 360 RC 12032 HCPCS outpatient 569.88 427.41 COORDINATED CARE MCAID COORDINATED CARE MCAID 484.8 85.07 999999999 444.51 541.39 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_2 CDM 360 RC 12032 HCPCS outpatient 569.88 427.41 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 484.8 85.07 999999999 444.51 541.39 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_2 CDM 360 RC 12032 HCPCS outpatient 569.88 427.41 MOLINA MCAID MOLINA MCAID 475.28 83.4 999999999 444.51 541.39 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_2 CDM 360 RC 12032 HCPCS outpatient 569.88 427.41 MOLINA MCR ADV MOLINA MCR ADV 507.19 89 999999999 444.51 541.39 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_2 CDM 360 RC 12032 HCPCS outpatient 569.88 427.41 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 507.19 89 999999999 444.51 541.39 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_2 CDM 360 RC 12032 HCPCS outpatient 569.88 427.41 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 507.19 89 999999999 444.51 541.39 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_2 CDM 360 RC 12032 HCPCS outpatient 569.88 427.41 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 512.89 90 999999999 444.51 541.39 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_2 CDM 360 RC 12032 HCPCS outpatient 569.88 427.41 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 541.39 95 999999999 444.51 541.39 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_2 CDM 360 RC 12032 HCPCS outpatient 569.88 427.41 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 541.39 95 999999999 444.51 541.39 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_2 CDM 360 RC 12032 HCPCS outpatient 569.88 427.41 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 507.19 89 999999999 444.51 541.39 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_2 CDM 360 RC 12032 HCPCS outpatient 569.88 427.41 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 501.49 88 999999999 444.51 541.39 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_2 CDM 360 RC 12032 HCPCS outpatient 569.88 427.41 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 507.19 89 999999999 444.51 541.39 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_3 CDM 360 RC 12032 HCPCS outpatient 626 469.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 563.4 999999999 488.28 594.7 case rate "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_3 CDM 360 RC 12032 HCPCS outpatient 626 469.5 AETNA MCR ADV AETNA MCR ADV 488.28 78 999999999 488.28 594.7 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_3 CDM 360 RC 12032 HCPCS outpatient 626 469.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 548.19 87.57 999999999 488.28 594.7 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_3 CDM 360 RC 12032 HCPCS outpatient 626 469.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 532.54 85.07 999999999 488.28 594.7 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_3 CDM 360 RC 12032 HCPCS outpatient 626 469.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 532.54 85.07 999999999 488.28 594.7 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_3 CDM 360 RC 12032 HCPCS outpatient 626 469.5 MOLINA MCAID MOLINA MCAID 522.08 83.4 999999999 488.28 594.7 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_3 CDM 360 RC 12032 HCPCS outpatient 626 469.5 MOLINA MCR ADV MOLINA MCR ADV 557.14 89 999999999 488.28 594.7 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_3 CDM 360 RC 12032 HCPCS outpatient 626 469.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 557.14 89 999999999 488.28 594.7 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_3 CDM 360 RC 12032 HCPCS outpatient 626 469.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 557.14 89 999999999 488.28 594.7 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_3 CDM 360 RC 12032 HCPCS outpatient 626 469.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 563.4 90 999999999 488.28 594.7 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_3 CDM 360 RC 12032 HCPCS outpatient 626 469.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 594.7 95 999999999 488.28 594.7 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_3 CDM 360 RC 12032 HCPCS outpatient 626 469.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 594.7 95 999999999 488.28 594.7 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_3 CDM 360 RC 12032 HCPCS outpatient 626 469.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 557.14 89 999999999 488.28 594.7 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_3 CDM 360 RC 12032 HCPCS outpatient 626 469.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 550.88 88 999999999 488.28 594.7 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 12032_3 CDM 360 RC 12032 HCPCS outpatient 626 469.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 557.14 89 999999999 488.28 594.7 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_1 CDM 360 RC 12034 HCPCS outpatient 570 427.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 513 999999999 444.6 541.5 case rate "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_1 CDM 360 RC 12034 HCPCS outpatient 570 427.5 AETNA MCR ADV AETNA MCR ADV 444.6 78 999999999 444.6 541.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_1 CDM 360 RC 12034 HCPCS outpatient 570 427.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 499.15 87.57 999999999 444.6 541.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_1 CDM 360 RC 12034 HCPCS outpatient 570 427.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 484.9 85.07 999999999 444.6 541.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_1 CDM 360 RC 12034 HCPCS outpatient 570 427.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 484.9 85.07 999999999 444.6 541.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_1 CDM 360 RC 12034 HCPCS outpatient 570 427.5 MOLINA MCAID MOLINA MCAID 475.38 83.4 999999999 444.6 541.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_1 CDM 360 RC 12034 HCPCS outpatient 570 427.5 MOLINA MCR ADV MOLINA MCR ADV 507.3 89 999999999 444.6 541.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_1 CDM 360 RC 12034 HCPCS outpatient 570 427.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 507.3 89 999999999 444.6 541.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_1 CDM 360 RC 12034 HCPCS outpatient 570 427.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 507.3 89 999999999 444.6 541.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_1 CDM 360 RC 12034 HCPCS outpatient 570 427.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 513 90 999999999 444.6 541.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_1 CDM 360 RC 12034 HCPCS outpatient 570 427.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 541.5 95 999999999 444.6 541.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_1 CDM 360 RC 12034 HCPCS outpatient 570 427.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 541.5 95 999999999 444.6 541.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_1 CDM 360 RC 12034 HCPCS outpatient 570 427.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 507.3 89 999999999 444.6 541.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_1 CDM 360 RC 12034 HCPCS outpatient 570 427.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 501.6 88 999999999 444.6 541.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_1 CDM 360 RC 12034 HCPCS outpatient 570 427.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 507.3 89 999999999 444.6 541.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_2 CDM 360 RC 12034 HCPCS outpatient 570 427.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 513 999999999 444.6 541.5 case rate "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_2 CDM 360 RC 12034 HCPCS outpatient 570 427.5 AETNA MCR ADV AETNA MCR ADV 444.6 78 999999999 444.6 541.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_2 CDM 360 RC 12034 HCPCS outpatient 570 427.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 499.15 87.57 999999999 444.6 541.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_2 CDM 360 RC 12034 HCPCS outpatient 570 427.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 484.9 85.07 999999999 444.6 541.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_2 CDM 360 RC 12034 HCPCS outpatient 570 427.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 484.9 85.07 999999999 444.6 541.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_2 CDM 360 RC 12034 HCPCS outpatient 570 427.5 MOLINA MCAID MOLINA MCAID 475.38 83.4 999999999 444.6 541.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_2 CDM 360 RC 12034 HCPCS outpatient 570 427.5 MOLINA MCR ADV MOLINA MCR ADV 507.3 89 999999999 444.6 541.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_2 CDM 360 RC 12034 HCPCS outpatient 570 427.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 507.3 89 999999999 444.6 541.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_2 CDM 360 RC 12034 HCPCS outpatient 570 427.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 507.3 89 999999999 444.6 541.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_2 CDM 360 RC 12034 HCPCS outpatient 570 427.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 513 90 999999999 444.6 541.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_2 CDM 360 RC 12034 HCPCS outpatient 570 427.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 541.5 95 999999999 444.6 541.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_2 CDM 360 RC 12034 HCPCS outpatient 570 427.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 541.5 95 999999999 444.6 541.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_2 CDM 360 RC 12034 HCPCS outpatient 570 427.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 507.3 89 999999999 444.6 541.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_2 CDM 360 RC 12034 HCPCS outpatient 570 427.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 501.6 88 999999999 444.6 541.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_2 CDM 360 RC 12034 HCPCS outpatient 570 427.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 507.3 89 999999999 444.6 541.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_3 CDM 360 RC 12034 HCPCS outpatient 690 517.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 621 999999999 538.2 655.5 case rate "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_3 CDM 360 RC 12034 HCPCS outpatient 690 517.5 AETNA MCR ADV AETNA MCR ADV 538.2 78 999999999 538.2 655.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_3 CDM 360 RC 12034 HCPCS outpatient 690 517.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 604.23 87.57 999999999 538.2 655.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_3 CDM 360 RC 12034 HCPCS outpatient 690 517.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 586.98 85.07 999999999 538.2 655.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_3 CDM 360 RC 12034 HCPCS outpatient 690 517.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 586.98 85.07 999999999 538.2 655.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_3 CDM 360 RC 12034 HCPCS outpatient 690 517.5 MOLINA MCAID MOLINA MCAID 575.46 83.4 999999999 538.2 655.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_3 CDM 360 RC 12034 HCPCS outpatient 690 517.5 MOLINA MCR ADV MOLINA MCR ADV 614.1 89 999999999 538.2 655.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_3 CDM 360 RC 12034 HCPCS outpatient 690 517.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 614.1 89 999999999 538.2 655.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_3 CDM 360 RC 12034 HCPCS outpatient 690 517.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 614.1 89 999999999 538.2 655.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_3 CDM 360 RC 12034 HCPCS outpatient 690 517.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 621 90 999999999 538.2 655.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_3 CDM 360 RC 12034 HCPCS outpatient 690 517.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 655.5 95 999999999 538.2 655.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_3 CDM 360 RC 12034 HCPCS outpatient 690 517.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 655.5 95 999999999 538.2 655.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_3 CDM 360 RC 12034 HCPCS outpatient 690 517.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 614.1 89 999999999 538.2 655.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_3 CDM 360 RC 12034 HCPCS outpatient 690 517.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 607.2 88 999999999 538.2 655.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 12034_3 CDM 360 RC 12034 HCPCS outpatient 690 517.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 614.1 89 999999999 538.2 655.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_1 CDM 360 RC 12035 HCPCS outpatient 723.36 542.52 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 651.02 999999999 564.22 687.19 case rate "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_1 CDM 360 RC 12035 HCPCS outpatient 723.36 542.52 AETNA MCR ADV AETNA MCR ADV 564.22 78 999999999 564.22 687.19 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_1 CDM 360 RC 12035 HCPCS outpatient 723.36 542.52 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 633.45 87.57 999999999 564.22 687.19 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_1 CDM 360 RC 12035 HCPCS outpatient 723.36 542.52 COORDINATED CARE MCAID COORDINATED CARE MCAID 615.36 85.07 999999999 564.22 687.19 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_1 CDM 360 RC 12035 HCPCS outpatient 723.36 542.52 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 615.36 85.07 999999999 564.22 687.19 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_1 CDM 360 RC 12035 HCPCS outpatient 723.36 542.52 MOLINA MCAID MOLINA MCAID 603.28 83.4 999999999 564.22 687.19 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_1 CDM 360 RC 12035 HCPCS outpatient 723.36 542.52 MOLINA MCR ADV MOLINA MCR ADV 643.79 89 999999999 564.22 687.19 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_1 CDM 360 RC 12035 HCPCS outpatient 723.36 542.52 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 643.79 89 999999999 564.22 687.19 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_1 CDM 360 RC 12035 HCPCS outpatient 723.36 542.52 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 643.79 89 999999999 564.22 687.19 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_1 CDM 360 RC 12035 HCPCS outpatient 723.36 542.52 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 651.02 90 999999999 564.22 687.19 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_1 CDM 360 RC 12035 HCPCS outpatient 723.36 542.52 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 687.19 95 999999999 564.22 687.19 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_1 CDM 360 RC 12035 HCPCS outpatient 723.36 542.52 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 687.19 95 999999999 564.22 687.19 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_1 CDM 360 RC 12035 HCPCS outpatient 723.36 542.52 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 643.79 89 999999999 564.22 687.19 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_1 CDM 360 RC 12035 HCPCS outpatient 723.36 542.52 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 636.56 88 999999999 564.22 687.19 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_1 CDM 360 RC 12035 HCPCS outpatient 723.36 542.52 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 643.79 89 999999999 564.22 687.19 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_2 CDM 360 RC 12035 HCPCS outpatient 723.36 542.52 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 651.02 999999999 564.22 687.19 case rate "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_2 CDM 360 RC 12035 HCPCS outpatient 723.36 542.52 AETNA MCR ADV AETNA MCR ADV 564.22 78 999999999 564.22 687.19 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_2 CDM 360 RC 12035 HCPCS outpatient 723.36 542.52 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 633.45 87.57 999999999 564.22 687.19 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_2 CDM 360 RC 12035 HCPCS outpatient 723.36 542.52 COORDINATED CARE MCAID COORDINATED CARE MCAID 615.36 85.07 999999999 564.22 687.19 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_2 CDM 360 RC 12035 HCPCS outpatient 723.36 542.52 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 615.36 85.07 999999999 564.22 687.19 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_2 CDM 360 RC 12035 HCPCS outpatient 723.36 542.52 MOLINA MCAID MOLINA MCAID 603.28 83.4 999999999 564.22 687.19 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_2 CDM 360 RC 12035 HCPCS outpatient 723.36 542.52 MOLINA MCR ADV MOLINA MCR ADV 643.79 89 999999999 564.22 687.19 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_2 CDM 360 RC 12035 HCPCS outpatient 723.36 542.52 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 643.79 89 999999999 564.22 687.19 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_2 CDM 360 RC 12035 HCPCS outpatient 723.36 542.52 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 643.79 89 999999999 564.22 687.19 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_2 CDM 360 RC 12035 HCPCS outpatient 723.36 542.52 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 651.02 90 999999999 564.22 687.19 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_2 CDM 360 RC 12035 HCPCS outpatient 723.36 542.52 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 687.19 95 999999999 564.22 687.19 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_2 CDM 360 RC 12035 HCPCS outpatient 723.36 542.52 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 687.19 95 999999999 564.22 687.19 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_2 CDM 360 RC 12035 HCPCS outpatient 723.36 542.52 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 643.79 89 999999999 564.22 687.19 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_2 CDM 360 RC 12035 HCPCS outpatient 723.36 542.52 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 636.56 88 999999999 564.22 687.19 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_2 CDM 360 RC 12035 HCPCS outpatient 723.36 542.52 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 643.79 89 999999999 564.22 687.19 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_3 CDM 360 RC 12035 HCPCS outpatient 802 601.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 721.8 999999999 625.56 761.9 case rate "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_3 CDM 360 RC 12035 HCPCS outpatient 802 601.5 AETNA MCR ADV AETNA MCR ADV 625.56 78 999999999 625.56 761.9 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_3 CDM 360 RC 12035 HCPCS outpatient 802 601.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 702.31 87.57 999999999 625.56 761.9 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_3 CDM 360 RC 12035 HCPCS outpatient 802 601.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 682.26 85.07 999999999 625.56 761.9 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_3 CDM 360 RC 12035 HCPCS outpatient 802 601.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 682.26 85.07 999999999 625.56 761.9 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_3 CDM 360 RC 12035 HCPCS outpatient 802 601.5 MOLINA MCAID MOLINA MCAID 668.87 83.4 999999999 625.56 761.9 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_3 CDM 360 RC 12035 HCPCS outpatient 802 601.5 MOLINA MCR ADV MOLINA MCR ADV 713.78 89 999999999 625.56 761.9 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_3 CDM 360 RC 12035 HCPCS outpatient 802 601.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 713.78 89 999999999 625.56 761.9 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_3 CDM 360 RC 12035 HCPCS outpatient 802 601.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 713.78 89 999999999 625.56 761.9 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_3 CDM 360 RC 12035 HCPCS outpatient 802 601.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 721.8 90 999999999 625.56 761.9 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_3 CDM 360 RC 12035 HCPCS outpatient 802 601.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 761.9 95 999999999 625.56 761.9 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_3 CDM 360 RC 12035 HCPCS outpatient 802 601.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 761.9 95 999999999 625.56 761.9 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_3 CDM 360 RC 12035 HCPCS outpatient 802 601.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 713.78 89 999999999 625.56 761.9 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_3 CDM 360 RC 12035 HCPCS outpatient 802 601.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 705.76 88 999999999 625.56 761.9 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 12035_3 CDM 360 RC 12035 HCPCS outpatient 802 601.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 713.78 89 999999999 625.56 761.9 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 12036_3 CDM 360 RC 12036 HCPCS outpatient 890 667.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 801 999999999 694.2 845.5 case rate "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 12036_3 CDM 360 RC 12036 HCPCS outpatient 890 667.5 AETNA MCR ADV AETNA MCR ADV 694.2 78 999999999 694.2 845.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 12036_3 CDM 360 RC 12036 HCPCS outpatient 890 667.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 779.37 87.57 999999999 694.2 845.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 12036_3 CDM 360 RC 12036 HCPCS outpatient 890 667.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 757.12 85.07 999999999 694.2 845.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 12036_3 CDM 360 RC 12036 HCPCS outpatient 890 667.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 757.12 85.07 999999999 694.2 845.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 12036_3 CDM 360 RC 12036 HCPCS outpatient 890 667.5 MOLINA MCAID MOLINA MCAID 742.26 83.4 999999999 694.2 845.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 12036_3 CDM 360 RC 12036 HCPCS outpatient 890 667.5 MOLINA MCR ADV MOLINA MCR ADV 792.1 89 999999999 694.2 845.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 12036_3 CDM 360 RC 12036 HCPCS outpatient 890 667.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 792.1 89 999999999 694.2 845.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 12036_3 CDM 360 RC 12036 HCPCS outpatient 890 667.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 792.1 89 999999999 694.2 845.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 12036_3 CDM 360 RC 12036 HCPCS outpatient 890 667.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 801 90 999999999 694.2 845.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 12036_3 CDM 360 RC 12036 HCPCS outpatient 890 667.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 845.5 95 999999999 694.2 845.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 12036_3 CDM 360 RC 12036 HCPCS outpatient 890 667.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 845.5 95 999999999 694.2 845.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 12036_3 CDM 360 RC 12036 HCPCS outpatient 890 667.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 792.1 89 999999999 694.2 845.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 12036_3 CDM 360 RC 12036 HCPCS outpatient 890 667.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 783.2 88 999999999 694.2 845.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 12036_3 CDM 360 RC 12036 HCPCS outpatient 890 667.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 792.1 89 999999999 694.2 845.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 12041_1 CDM 360 RC 12041 HCPCS outpatient 433.14 324.86 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 389.83 999999999 337.85 411.48 case rate "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 12041_1 CDM 360 RC 12041 HCPCS outpatient 433.14 324.86 AETNA MCR ADV AETNA MCR ADV 337.85 78 999999999 337.85 411.48 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 12041_1 CDM 360 RC 12041 HCPCS outpatient 433.14 324.86 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 379.3 87.57 999999999 337.85 411.48 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 12041_1 CDM 360 RC 12041 HCPCS outpatient 433.14 324.86 COORDINATED CARE MCAID COORDINATED CARE MCAID 368.47 85.07 999999999 337.85 411.48 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 12041_1 CDM 360 RC 12041 HCPCS outpatient 433.14 324.86 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 368.47 85.07 999999999 337.85 411.48 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 12041_1 CDM 360 RC 12041 HCPCS outpatient 433.14 324.86 MOLINA MCAID MOLINA MCAID 361.24 83.4 999999999 337.85 411.48 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 12041_1 CDM 360 RC 12041 HCPCS outpatient 433.14 324.86 MOLINA MCR ADV MOLINA MCR ADV 385.49 89 999999999 337.85 411.48 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 12041_1 CDM 360 RC 12041 HCPCS outpatient 433.14 324.86 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 385.49 89 999999999 337.85 411.48 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 12041_1 CDM 360 RC 12041 HCPCS outpatient 433.14 324.86 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 385.49 89 999999999 337.85 411.48 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 12041_1 CDM 360 RC 12041 HCPCS outpatient 433.14 324.86 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 389.83 90 999999999 337.85 411.48 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 12041_1 CDM 360 RC 12041 HCPCS outpatient 433.14 324.86 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 411.48 95 999999999 337.85 411.48 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 12041_1 CDM 360 RC 12041 HCPCS outpatient 433.14 324.86 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 411.48 95 999999999 337.85 411.48 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 12041_1 CDM 360 RC 12041 HCPCS outpatient 433.14 324.86 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 385.49 89 999999999 337.85 411.48 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 12041_1 CDM 360 RC 12041 HCPCS outpatient 433.14 324.86 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 381.16 88 999999999 337.85 411.48 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 12041_1 CDM 360 RC 12041 HCPCS outpatient 433.14 324.86 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 385.49 89 999999999 337.85 411.48 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 12041_3 CDM 360 RC 12041 HCPCS outpatient 550 412.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 495 999999999 429 522.5 case rate "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 12041_3 CDM 360 RC 12041 HCPCS outpatient 550 412.5 AETNA MCR ADV AETNA MCR ADV 429 78 999999999 429 522.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 12041_3 CDM 360 RC 12041 HCPCS outpatient 550 412.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 481.64 87.57 999999999 429 522.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 12041_3 CDM 360 RC 12041 HCPCS outpatient 550 412.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 467.89 85.07 999999999 429 522.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 12041_3 CDM 360 RC 12041 HCPCS outpatient 550 412.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 467.89 85.07 999999999 429 522.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 12041_3 CDM 360 RC 12041 HCPCS outpatient 550 412.5 MOLINA MCAID MOLINA MCAID 458.7 83.4 999999999 429 522.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 12041_3 CDM 360 RC 12041 HCPCS outpatient 550 412.5 MOLINA MCR ADV MOLINA MCR ADV 489.5 89 999999999 429 522.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 12041_3 CDM 360 RC 12041 HCPCS outpatient 550 412.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 489.5 89 999999999 429 522.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 12041_3 CDM 360 RC 12041 HCPCS outpatient 550 412.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 489.5 89 999999999 429 522.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 12041_3 CDM 360 RC 12041 HCPCS outpatient 550 412.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 495 90 999999999 429 522.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 12041_3 CDM 360 RC 12041 HCPCS outpatient 550 412.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 522.5 95 999999999 429 522.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 12041_3 CDM 360 RC 12041 HCPCS outpatient 550 412.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 522.5 95 999999999 429 522.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 12041_3 CDM 360 RC 12041 HCPCS outpatient 550 412.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 489.5 89 999999999 429 522.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 12041_3 CDM 360 RC 12041 HCPCS outpatient 550 412.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 484 88 999999999 429 522.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 12041_3 CDM 360 RC 12041 HCPCS outpatient 550 412.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 489.5 89 999999999 429 522.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_1 CDM 360 RC 12042 HCPCS outpatient 588.09 441.07 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 529.28 999999999 458.71 558.69 case rate "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_1 CDM 360 RC 12042 HCPCS outpatient 588.09 441.07 AETNA MCR ADV AETNA MCR ADV 458.71 78 999999999 458.71 558.69 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_1 CDM 360 RC 12042 HCPCS outpatient 588.09 441.07 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 514.99 87.57 999999999 458.71 558.69 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_1 CDM 360 RC 12042 HCPCS outpatient 588.09 441.07 COORDINATED CARE MCAID COORDINATED CARE MCAID 500.29 85.07 999999999 458.71 558.69 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_1 CDM 360 RC 12042 HCPCS outpatient 588.09 441.07 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 500.29 85.07 999999999 458.71 558.69 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_1 CDM 360 RC 12042 HCPCS outpatient 588.09 441.07 MOLINA MCAID MOLINA MCAID 490.47 83.4 999999999 458.71 558.69 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_1 CDM 360 RC 12042 HCPCS outpatient 588.09 441.07 MOLINA MCR ADV MOLINA MCR ADV 523.4 89 999999999 458.71 558.69 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_1 CDM 360 RC 12042 HCPCS outpatient 588.09 441.07 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 523.4 89 999999999 458.71 558.69 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_1 CDM 360 RC 12042 HCPCS outpatient 588.09 441.07 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 523.4 89 999999999 458.71 558.69 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_1 CDM 360 RC 12042 HCPCS outpatient 588.09 441.07 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 529.28 90 999999999 458.71 558.69 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_1 CDM 360 RC 12042 HCPCS outpatient 588.09 441.07 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 558.69 95 999999999 458.71 558.69 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_1 CDM 360 RC 12042 HCPCS outpatient 588.09 441.07 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 558.69 95 999999999 458.71 558.69 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_1 CDM 360 RC 12042 HCPCS outpatient 588.09 441.07 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 523.4 89 999999999 458.71 558.69 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_1 CDM 360 RC 12042 HCPCS outpatient 588.09 441.07 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 517.52 88 999999999 458.71 558.69 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_1 CDM 360 RC 12042 HCPCS outpatient 588.09 441.07 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 523.4 89 999999999 458.71 558.69 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_2 CDM 360 RC 12042 HCPCS outpatient 588.09 441.07 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 529.28 999999999 458.71 558.69 case rate "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_2 CDM 360 RC 12042 HCPCS outpatient 588.09 441.07 AETNA MCR ADV AETNA MCR ADV 458.71 78 999999999 458.71 558.69 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_2 CDM 360 RC 12042 HCPCS outpatient 588.09 441.07 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 514.99 87.57 999999999 458.71 558.69 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_2 CDM 360 RC 12042 HCPCS outpatient 588.09 441.07 COORDINATED CARE MCAID COORDINATED CARE MCAID 500.29 85.07 999999999 458.71 558.69 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_2 CDM 360 RC 12042 HCPCS outpatient 588.09 441.07 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 500.29 85.07 999999999 458.71 558.69 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_2 CDM 360 RC 12042 HCPCS outpatient 588.09 441.07 MOLINA MCAID MOLINA MCAID 490.47 83.4 999999999 458.71 558.69 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_2 CDM 360 RC 12042 HCPCS outpatient 588.09 441.07 MOLINA MCR ADV MOLINA MCR ADV 523.4 89 999999999 458.71 558.69 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_2 CDM 360 RC 12042 HCPCS outpatient 588.09 441.07 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 523.4 89 999999999 458.71 558.69 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_2 CDM 360 RC 12042 HCPCS outpatient 588.09 441.07 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 523.4 89 999999999 458.71 558.69 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_2 CDM 360 RC 12042 HCPCS outpatient 588.09 441.07 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 529.28 90 999999999 458.71 558.69 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_2 CDM 360 RC 12042 HCPCS outpatient 588.09 441.07 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 558.69 95 999999999 458.71 558.69 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_2 CDM 360 RC 12042 HCPCS outpatient 588.09 441.07 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 558.69 95 999999999 458.71 558.69 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_2 CDM 360 RC 12042 HCPCS outpatient 588.09 441.07 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 523.4 89 999999999 458.71 558.69 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_2 CDM 360 RC 12042 HCPCS outpatient 588.09 441.07 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 517.52 88 999999999 458.71 558.69 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_2 CDM 360 RC 12042 HCPCS outpatient 588.09 441.07 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 523.4 89 999999999 458.71 558.69 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_3 CDM 360 RC 12042 HCPCS outpatient 640 480 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 576 999999999 499.2 608 case rate "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_3 CDM 360 RC 12042 HCPCS outpatient 640 480 AETNA MCR ADV AETNA MCR ADV 499.2 78 999999999 499.2 608 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_3 CDM 360 RC 12042 HCPCS outpatient 640 480 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 560.45 87.57 999999999 499.2 608 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_3 CDM 360 RC 12042 HCPCS outpatient 640 480 COORDINATED CARE MCAID COORDINATED CARE MCAID 544.45 85.07 999999999 499.2 608 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_3 CDM 360 RC 12042 HCPCS outpatient 640 480 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 544.45 85.07 999999999 499.2 608 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_3 CDM 360 RC 12042 HCPCS outpatient 640 480 MOLINA MCAID MOLINA MCAID 533.76 83.4 999999999 499.2 608 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_3 CDM 360 RC 12042 HCPCS outpatient 640 480 MOLINA MCR ADV MOLINA MCR ADV 569.6 89 999999999 499.2 608 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_3 CDM 360 RC 12042 HCPCS outpatient 640 480 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 569.6 89 999999999 499.2 608 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_3 CDM 360 RC 12042 HCPCS outpatient 640 480 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 569.6 89 999999999 499.2 608 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_3 CDM 360 RC 12042 HCPCS outpatient 640 480 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 576 90 999999999 499.2 608 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_3 CDM 360 RC 12042 HCPCS outpatient 640 480 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 608 95 999999999 499.2 608 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_3 CDM 360 RC 12042 HCPCS outpatient 640 480 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 608 95 999999999 499.2 608 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_3 CDM 360 RC 12042 HCPCS outpatient 640 480 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 569.6 89 999999999 499.2 608 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_3 CDM 360 RC 12042 HCPCS outpatient 640 480 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 563.2 88 999999999 499.2 608 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 12042_3 CDM 360 RC 12042 HCPCS outpatient 640 480 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 569.6 89 999999999 499.2 608 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 7.6 CM TO 12.5 CM" 12044_3 CDM 360 RC 12044 HCPCS outpatient 800 600 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 720 999999999 624 760 case rate "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 7.6 CM TO 12.5 CM" 12044_3 CDM 360 RC 12044 HCPCS outpatient 800 600 AETNA MCR ADV AETNA MCR ADV 624 78 999999999 624 760 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 7.6 CM TO 12.5 CM" 12044_3 CDM 360 RC 12044 HCPCS outpatient 800 600 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 700.56 87.57 999999999 624 760 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 7.6 CM TO 12.5 CM" 12044_3 CDM 360 RC 12044 HCPCS outpatient 800 600 COORDINATED CARE MCAID COORDINATED CARE MCAID 680.56 85.07 999999999 624 760 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 7.6 CM TO 12.5 CM" 12044_3 CDM 360 RC 12044 HCPCS outpatient 800 600 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 680.56 85.07 999999999 624 760 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 7.6 CM TO 12.5 CM" 12044_3 CDM 360 RC 12044 HCPCS outpatient 800 600 MOLINA MCAID MOLINA MCAID 667.2 83.4 999999999 624 760 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 7.6 CM TO 12.5 CM" 12044_3 CDM 360 RC 12044 HCPCS outpatient 800 600 MOLINA MCR ADV MOLINA MCR ADV 712 89 999999999 624 760 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 7.6 CM TO 12.5 CM" 12044_3 CDM 360 RC 12044 HCPCS outpatient 800 600 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 712 89 999999999 624 760 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 7.6 CM TO 12.5 CM" 12044_3 CDM 360 RC 12044 HCPCS outpatient 800 600 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 712 89 999999999 624 760 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 7.6 CM TO 12.5 CM" 12044_3 CDM 360 RC 12044 HCPCS outpatient 800 600 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 720 90 999999999 624 760 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 7.6 CM TO 12.5 CM" 12044_3 CDM 360 RC 12044 HCPCS outpatient 800 600 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 760 95 999999999 624 760 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 7.6 CM TO 12.5 CM" 12044_3 CDM 360 RC 12044 HCPCS outpatient 800 600 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 760 95 999999999 624 760 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 7.6 CM TO 12.5 CM" 12044_3 CDM 360 RC 12044 HCPCS outpatient 800 600 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 712 89 999999999 624 760 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 7.6 CM TO 12.5 CM" 12044_3 CDM 360 RC 12044 HCPCS outpatient 800 600 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 704 88 999999999 624 760 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 7.6 CM TO 12.5 CM" 12044_3 CDM 360 RC 12044 HCPCS outpatient 800 600 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 712 89 999999999 624 760 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 12.6 CM TO 20.0 CM" 12045_3 CDM 360 RC 12045 HCPCS outpatient 840 630 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 756 999999999 655.2 798 case rate "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 12.6 CM TO 20.0 CM" 12045_3 CDM 360 RC 12045 HCPCS outpatient 840 630 AETNA MCR ADV AETNA MCR ADV 655.2 78 999999999 655.2 798 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 12.6 CM TO 20.0 CM" 12045_3 CDM 360 RC 12045 HCPCS outpatient 840 630 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 735.59 87.57 999999999 655.2 798 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 12.6 CM TO 20.0 CM" 12045_3 CDM 360 RC 12045 HCPCS outpatient 840 630 COORDINATED CARE MCAID COORDINATED CARE MCAID 714.59 85.07 999999999 655.2 798 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 12.6 CM TO 20.0 CM" 12045_3 CDM 360 RC 12045 HCPCS outpatient 840 630 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 714.59 85.07 999999999 655.2 798 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 12.6 CM TO 20.0 CM" 12045_3 CDM 360 RC 12045 HCPCS outpatient 840 630 MOLINA MCAID MOLINA MCAID 700.56 83.4 999999999 655.2 798 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 12.6 CM TO 20.0 CM" 12045_3 CDM 360 RC 12045 HCPCS outpatient 840 630 MOLINA MCR ADV MOLINA MCR ADV 747.6 89 999999999 655.2 798 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 12.6 CM TO 20.0 CM" 12045_3 CDM 360 RC 12045 HCPCS outpatient 840 630 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 747.6 89 999999999 655.2 798 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 12.6 CM TO 20.0 CM" 12045_3 CDM 360 RC 12045 HCPCS outpatient 840 630 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 747.6 89 999999999 655.2 798 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 12.6 CM TO 20.0 CM" 12045_3 CDM 360 RC 12045 HCPCS outpatient 840 630 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 756 90 999999999 655.2 798 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 12.6 CM TO 20.0 CM" 12045_3 CDM 360 RC 12045 HCPCS outpatient 840 630 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 798 95 999999999 655.2 798 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 12.6 CM TO 20.0 CM" 12045_3 CDM 360 RC 12045 HCPCS outpatient 840 630 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 798 95 999999999 655.2 798 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 12.6 CM TO 20.0 CM" 12045_3 CDM 360 RC 12045 HCPCS outpatient 840 630 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 747.6 89 999999999 655.2 798 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 12.6 CM TO 20.0 CM" 12045_3 CDM 360 RC 12045 HCPCS outpatient 840 630 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 739.2 88 999999999 655.2 798 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 12.6 CM TO 20.0 CM" 12045_3 CDM 360 RC 12045 HCPCS outpatient 840 630 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 747.6 89 999999999 655.2 798 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 20.1 CM TO 30.0 CM" 12046_3 CDM 360 RC 12046 HCPCS outpatient 1034 775.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 930.6 999999999 806.52 982.3 case rate "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 20.1 CM TO 30.0 CM" 12046_3 CDM 360 RC 12046 HCPCS outpatient 1034 775.5 AETNA MCR ADV AETNA MCR ADV 806.52 78 999999999 806.52 982.3 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 20.1 CM TO 30.0 CM" 12046_3 CDM 360 RC 12046 HCPCS outpatient 1034 775.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 905.47 87.57 999999999 806.52 982.3 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 20.1 CM TO 30.0 CM" 12046_3 CDM 360 RC 12046 HCPCS outpatient 1034 775.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 879.62 85.07 999999999 806.52 982.3 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 20.1 CM TO 30.0 CM" 12046_3 CDM 360 RC 12046 HCPCS outpatient 1034 775.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 879.62 85.07 999999999 806.52 982.3 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 20.1 CM TO 30.0 CM" 12046_3 CDM 360 RC 12046 HCPCS outpatient 1034 775.5 MOLINA MCAID MOLINA MCAID 862.36 83.4 999999999 806.52 982.3 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 20.1 CM TO 30.0 CM" 12046_3 CDM 360 RC 12046 HCPCS outpatient 1034 775.5 MOLINA MCR ADV MOLINA MCR ADV 920.26 89 999999999 806.52 982.3 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 20.1 CM TO 30.0 CM" 12046_3 CDM 360 RC 12046 HCPCS outpatient 1034 775.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 920.26 89 999999999 806.52 982.3 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 20.1 CM TO 30.0 CM" 12046_3 CDM 360 RC 12046 HCPCS outpatient 1034 775.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 920.26 89 999999999 806.52 982.3 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 20.1 CM TO 30.0 CM" 12046_3 CDM 360 RC 12046 HCPCS outpatient 1034 775.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 930.6 90 999999999 806.52 982.3 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 20.1 CM TO 30.0 CM" 12046_3 CDM 360 RC 12046 HCPCS outpatient 1034 775.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 982.3 95 999999999 806.52 982.3 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 20.1 CM TO 30.0 CM" 12046_3 CDM 360 RC 12046 HCPCS outpatient 1034 775.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 982.3 95 999999999 806.52 982.3 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 20.1 CM TO 30.0 CM" 12046_3 CDM 360 RC 12046 HCPCS outpatient 1034 775.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 920.26 89 999999999 806.52 982.3 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 20.1 CM TO 30.0 CM" 12046_3 CDM 360 RC 12046 HCPCS outpatient 1034 775.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 909.92 88 999999999 806.52 982.3 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 20.1 CM TO 30.0 CM" 12046_3 CDM 360 RC 12046 HCPCS outpatient 1034 775.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 920.26 89 999999999 806.52 982.3 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12051_3 CDM 360 RC 12051 HCPCS outpatient 600 450 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 540 999999999 468 570 case rate "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12051_3 CDM 360 RC 12051 HCPCS outpatient 600 450 AETNA MCR ADV AETNA MCR ADV 468 78 999999999 468 570 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12051_3 CDM 360 RC 12051 HCPCS outpatient 600 450 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 525.42 87.57 999999999 468 570 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12051_3 CDM 360 RC 12051 HCPCS outpatient 600 450 COORDINATED CARE MCAID COORDINATED CARE MCAID 510.42 85.07 999999999 468 570 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12051_3 CDM 360 RC 12051 HCPCS outpatient 600 450 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 510.42 85.07 999999999 468 570 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12051_3 CDM 360 RC 12051 HCPCS outpatient 600 450 MOLINA MCAID MOLINA MCAID 500.4 83.4 999999999 468 570 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12051_3 CDM 360 RC 12051 HCPCS outpatient 600 450 MOLINA MCR ADV MOLINA MCR ADV 534 89 999999999 468 570 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12051_3 CDM 360 RC 12051 HCPCS outpatient 600 450 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 534 89 999999999 468 570 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12051_3 CDM 360 RC 12051 HCPCS outpatient 600 450 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 534 89 999999999 468 570 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12051_3 CDM 360 RC 12051 HCPCS outpatient 600 450 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 540 90 999999999 468 570 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12051_3 CDM 360 RC 12051 HCPCS outpatient 600 450 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 570 95 999999999 468 570 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12051_3 CDM 360 RC 12051 HCPCS outpatient 600 450 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 570 95 999999999 468 570 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12051_3 CDM 360 RC 12051 HCPCS outpatient 600 450 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 534 89 999999999 468 570 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12051_3 CDM 360 RC 12051 HCPCS outpatient 600 450 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 528 88 999999999 468 570 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 12051_3 CDM 360 RC 12051 HCPCS outpatient 600 450 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 534 89 999999999 468 570 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_1 CDM 360 RC 12052 HCPCS outpatient 597.93 448.45 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 538.14 999999999 466.39 568.03 case rate "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_1 CDM 360 RC 12052 HCPCS outpatient 597.93 448.45 AETNA MCR ADV AETNA MCR ADV 466.39 78 999999999 466.39 568.03 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_1 CDM 360 RC 12052 HCPCS outpatient 597.93 448.45 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 523.61 87.57 999999999 466.39 568.03 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_1 CDM 360 RC 12052 HCPCS outpatient 597.93 448.45 COORDINATED CARE MCAID COORDINATED CARE MCAID 508.66 85.07 999999999 466.39 568.03 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_1 CDM 360 RC 12052 HCPCS outpatient 597.93 448.45 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 508.66 85.07 999999999 466.39 568.03 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_1 CDM 360 RC 12052 HCPCS outpatient 597.93 448.45 MOLINA MCAID MOLINA MCAID 498.67 83.4 999999999 466.39 568.03 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_1 CDM 360 RC 12052 HCPCS outpatient 597.93 448.45 MOLINA MCR ADV MOLINA MCR ADV 532.16 89 999999999 466.39 568.03 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_1 CDM 360 RC 12052 HCPCS outpatient 597.93 448.45 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 532.16 89 999999999 466.39 568.03 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_1 CDM 360 RC 12052 HCPCS outpatient 597.93 448.45 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 532.16 89 999999999 466.39 568.03 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_1 CDM 360 RC 12052 HCPCS outpatient 597.93 448.45 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 538.14 90 999999999 466.39 568.03 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_1 CDM 360 RC 12052 HCPCS outpatient 597.93 448.45 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 568.03 95 999999999 466.39 568.03 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_1 CDM 360 RC 12052 HCPCS outpatient 597.93 448.45 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 568.03 95 999999999 466.39 568.03 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_1 CDM 360 RC 12052 HCPCS outpatient 597.93 448.45 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 532.16 89 999999999 466.39 568.03 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_1 CDM 360 RC 12052 HCPCS outpatient 597.93 448.45 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 526.18 88 999999999 466.39 568.03 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_1 CDM 360 RC 12052 HCPCS outpatient 597.93 448.45 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 532.16 89 999999999 466.39 568.03 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_2 CDM 360 RC 12052 HCPCS outpatient 597.93 448.45 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 538.14 999999999 466.39 568.03 case rate "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_2 CDM 360 RC 12052 HCPCS outpatient 597.93 448.45 AETNA MCR ADV AETNA MCR ADV 466.39 78 999999999 466.39 568.03 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_2 CDM 360 RC 12052 HCPCS outpatient 597.93 448.45 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 523.61 87.57 999999999 466.39 568.03 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_2 CDM 360 RC 12052 HCPCS outpatient 597.93 448.45 COORDINATED CARE MCAID COORDINATED CARE MCAID 508.66 85.07 999999999 466.39 568.03 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_2 CDM 360 RC 12052 HCPCS outpatient 597.93 448.45 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 508.66 85.07 999999999 466.39 568.03 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_2 CDM 360 RC 12052 HCPCS outpatient 597.93 448.45 MOLINA MCAID MOLINA MCAID 498.67 83.4 999999999 466.39 568.03 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_2 CDM 360 RC 12052 HCPCS outpatient 597.93 448.45 MOLINA MCR ADV MOLINA MCR ADV 532.16 89 999999999 466.39 568.03 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_2 CDM 360 RC 12052 HCPCS outpatient 597.93 448.45 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 532.16 89 999999999 466.39 568.03 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_2 CDM 360 RC 12052 HCPCS outpatient 597.93 448.45 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 532.16 89 999999999 466.39 568.03 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_2 CDM 360 RC 12052 HCPCS outpatient 597.93 448.45 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 538.14 90 999999999 466.39 568.03 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_2 CDM 360 RC 12052 HCPCS outpatient 597.93 448.45 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 568.03 95 999999999 466.39 568.03 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_2 CDM 360 RC 12052 HCPCS outpatient 597.93 448.45 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 568.03 95 999999999 466.39 568.03 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_2 CDM 360 RC 12052 HCPCS outpatient 597.93 448.45 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 532.16 89 999999999 466.39 568.03 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_2 CDM 360 RC 12052 HCPCS outpatient 597.93 448.45 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 526.18 88 999999999 466.39 568.03 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_2 CDM 360 RC 12052 HCPCS outpatient 597.93 448.45 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 532.16 89 999999999 466.39 568.03 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_3 CDM 360 RC 12052 HCPCS outpatient 752 564 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 676.8 999999999 586.56 714.4 case rate "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_3 CDM 360 RC 12052 HCPCS outpatient 752 564 AETNA MCR ADV AETNA MCR ADV 586.56 78 999999999 586.56 714.4 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_3 CDM 360 RC 12052 HCPCS outpatient 752 564 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 658.53 87.57 999999999 586.56 714.4 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_3 CDM 360 RC 12052 HCPCS outpatient 752 564 COORDINATED CARE MCAID COORDINATED CARE MCAID 639.73 85.07 999999999 586.56 714.4 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_3 CDM 360 RC 12052 HCPCS outpatient 752 564 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 639.73 85.07 999999999 586.56 714.4 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_3 CDM 360 RC 12052 HCPCS outpatient 752 564 MOLINA MCAID MOLINA MCAID 627.17 83.4 999999999 586.56 714.4 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_3 CDM 360 RC 12052 HCPCS outpatient 752 564 MOLINA MCR ADV MOLINA MCR ADV 669.28 89 999999999 586.56 714.4 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_3 CDM 360 RC 12052 HCPCS outpatient 752 564 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 669.28 89 999999999 586.56 714.4 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_3 CDM 360 RC 12052 HCPCS outpatient 752 564 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 669.28 89 999999999 586.56 714.4 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_3 CDM 360 RC 12052 HCPCS outpatient 752 564 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 676.8 90 999999999 586.56 714.4 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_3 CDM 360 RC 12052 HCPCS outpatient 752 564 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 714.4 95 999999999 586.56 714.4 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_3 CDM 360 RC 12052 HCPCS outpatient 752 564 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 714.4 95 999999999 586.56 714.4 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_3 CDM 360 RC 12052 HCPCS outpatient 752 564 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 669.28 89 999999999 586.56 714.4 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_3 CDM 360 RC 12052 HCPCS outpatient 752 564 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 661.76 88 999999999 586.56 714.4 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 12052_3 CDM 360 RC 12052 HCPCS outpatient 752 564 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 669.28 89 999999999 586.56 714.4 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12053_3 CDM 360 RC 12053 HCPCS outpatient 754 565.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 678.6 999999999 588.12 716.3 case rate "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12053_3 CDM 360 RC 12053 HCPCS outpatient 754 565.5 AETNA MCR ADV AETNA MCR ADV 588.12 78 999999999 588.12 716.3 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12053_3 CDM 360 RC 12053 HCPCS outpatient 754 565.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 660.28 87.57 999999999 588.12 716.3 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12053_3 CDM 360 RC 12053 HCPCS outpatient 754 565.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 641.43 85.07 999999999 588.12 716.3 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12053_3 CDM 360 RC 12053 HCPCS outpatient 754 565.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 641.43 85.07 999999999 588.12 716.3 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12053_3 CDM 360 RC 12053 HCPCS outpatient 754 565.5 MOLINA MCAID MOLINA MCAID 628.84 83.4 999999999 588.12 716.3 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12053_3 CDM 360 RC 12053 HCPCS outpatient 754 565.5 MOLINA MCR ADV MOLINA MCR ADV 671.06 89 999999999 588.12 716.3 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12053_3 CDM 360 RC 12053 HCPCS outpatient 754 565.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 671.06 89 999999999 588.12 716.3 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12053_3 CDM 360 RC 12053 HCPCS outpatient 754 565.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 671.06 89 999999999 588.12 716.3 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12053_3 CDM 360 RC 12053 HCPCS outpatient 754 565.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 678.6 90 999999999 588.12 716.3 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12053_3 CDM 360 RC 12053 HCPCS outpatient 754 565.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 716.3 95 999999999 588.12 716.3 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12053_3 CDM 360 RC 12053 HCPCS outpatient 754 565.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 716.3 95 999999999 588.12 716.3 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12053_3 CDM 360 RC 12053 HCPCS outpatient 754 565.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 671.06 89 999999999 588.12 716.3 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12053_3 CDM 360 RC 12053 HCPCS outpatient 754 565.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 663.52 88 999999999 588.12 716.3 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 12053_3 CDM 360 RC 12053 HCPCS outpatient 754 565.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 671.06 89 999999999 588.12 716.3 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12054_3 CDM 360 RC 12054 HCPCS outpatient 800 600 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 720 999999999 624 760 case rate "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12054_3 CDM 360 RC 12054 HCPCS outpatient 800 600 AETNA MCR ADV AETNA MCR ADV 624 78 999999999 624 760 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12054_3 CDM 360 RC 12054 HCPCS outpatient 800 600 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 700.56 87.57 999999999 624 760 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12054_3 CDM 360 RC 12054 HCPCS outpatient 800 600 COORDINATED CARE MCAID COORDINATED CARE MCAID 680.56 85.07 999999999 624 760 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12054_3 CDM 360 RC 12054 HCPCS outpatient 800 600 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 680.56 85.07 999999999 624 760 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12054_3 CDM 360 RC 12054 HCPCS outpatient 800 600 MOLINA MCAID MOLINA MCAID 667.2 83.4 999999999 624 760 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12054_3 CDM 360 RC 12054 HCPCS outpatient 800 600 MOLINA MCR ADV MOLINA MCR ADV 712 89 999999999 624 760 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12054_3 CDM 360 RC 12054 HCPCS outpatient 800 600 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 712 89 999999999 624 760 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12054_3 CDM 360 RC 12054 HCPCS outpatient 800 600 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 712 89 999999999 624 760 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12054_3 CDM 360 RC 12054 HCPCS outpatient 800 600 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 720 90 999999999 624 760 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12054_3 CDM 360 RC 12054 HCPCS outpatient 800 600 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 760 95 999999999 624 760 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12054_3 CDM 360 RC 12054 HCPCS outpatient 800 600 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 760 95 999999999 624 760 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12054_3 CDM 360 RC 12054 HCPCS outpatient 800 600 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 712 89 999999999 624 760 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12054_3 CDM 360 RC 12054 HCPCS outpatient 800 600 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 704 88 999999999 624 760 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 12054_3 CDM 360 RC 12054 HCPCS outpatient 800 600 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 712 89 999999999 624 760 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12055_3 CDM 360 RC 12055 HCPCS outpatient 1040 780 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 936 999999999 811.2 988 case rate "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12055_3 CDM 360 RC 12055 HCPCS outpatient 1040 780 AETNA MCR ADV AETNA MCR ADV 811.2 78 999999999 811.2 988 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12055_3 CDM 360 RC 12055 HCPCS outpatient 1040 780 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 910.73 87.57 999999999 811.2 988 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12055_3 CDM 360 RC 12055 HCPCS outpatient 1040 780 COORDINATED CARE MCAID COORDINATED CARE MCAID 884.73 85.07 999999999 811.2 988 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12055_3 CDM 360 RC 12055 HCPCS outpatient 1040 780 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 884.73 85.07 999999999 811.2 988 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12055_3 CDM 360 RC 12055 HCPCS outpatient 1040 780 MOLINA MCAID MOLINA MCAID 867.36 83.4 999999999 811.2 988 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12055_3 CDM 360 RC 12055 HCPCS outpatient 1040 780 MOLINA MCR ADV MOLINA MCR ADV 925.6 89 999999999 811.2 988 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12055_3 CDM 360 RC 12055 HCPCS outpatient 1040 780 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 925.6 89 999999999 811.2 988 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12055_3 CDM 360 RC 12055 HCPCS outpatient 1040 780 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 925.6 89 999999999 811.2 988 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12055_3 CDM 360 RC 12055 HCPCS outpatient 1040 780 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 936 90 999999999 811.2 988 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12055_3 CDM 360 RC 12055 HCPCS outpatient 1040 780 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 988 95 999999999 811.2 988 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12055_3 CDM 360 RC 12055 HCPCS outpatient 1040 780 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 988 95 999999999 811.2 988 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12055_3 CDM 360 RC 12055 HCPCS outpatient 1040 780 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 925.6 89 999999999 811.2 988 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12055_3 CDM 360 RC 12055 HCPCS outpatient 1040 780 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 915.2 88 999999999 811.2 988 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 12055_3 CDM 360 RC 12055 HCPCS outpatient 1040 780 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 925.6 89 999999999 811.2 988 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12056_3 CDM 360 RC 12056 HCPCS outpatient 1200 900 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1080 999999999 936 1140 case rate "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12056_3 CDM 360 RC 12056 HCPCS outpatient 1200 900 AETNA MCR ADV AETNA MCR ADV 936 78 999999999 936 1140 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12056_3 CDM 360 RC 12056 HCPCS outpatient 1200 900 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1050.84 87.57 999999999 936 1140 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12056_3 CDM 360 RC 12056 HCPCS outpatient 1200 900 COORDINATED CARE MCAID COORDINATED CARE MCAID 1020.84 85.07 999999999 936 1140 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12056_3 CDM 360 RC 12056 HCPCS outpatient 1200 900 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1020.84 85.07 999999999 936 1140 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12056_3 CDM 360 RC 12056 HCPCS outpatient 1200 900 MOLINA MCAID MOLINA MCAID 1000.8 83.4 999999999 936 1140 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12056_3 CDM 360 RC 12056 HCPCS outpatient 1200 900 MOLINA MCR ADV MOLINA MCR ADV 1068 89 999999999 936 1140 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12056_3 CDM 360 RC 12056 HCPCS outpatient 1200 900 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1068 89 999999999 936 1140 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12056_3 CDM 360 RC 12056 HCPCS outpatient 1200 900 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1068 89 999999999 936 1140 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12056_3 CDM 360 RC 12056 HCPCS outpatient 1200 900 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1080 90 999999999 936 1140 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12056_3 CDM 360 RC 12056 HCPCS outpatient 1200 900 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1140 95 999999999 936 1140 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12056_3 CDM 360 RC 12056 HCPCS outpatient 1200 900 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1140 95 999999999 936 1140 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12056_3 CDM 360 RC 12056 HCPCS outpatient 1200 900 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1068 89 999999999 936 1140 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12056_3 CDM 360 RC 12056 HCPCS outpatient 1200 900 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1056 88 999999999 936 1140 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 12056_3 CDM 360 RC 12056 HCPCS outpatient 1200 900 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1068 89 999999999 936 1140 percent of total billed charges "REPAIR, COMPLEX, TRUNK; 1.1 CM TO 2.5 CM" 13100_3 CDM 360 RC 13100 HCPCS outpatient 706 529.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 635.4 999999999 550.68 670.7 case rate "REPAIR, COMPLEX, TRUNK; 1.1 CM TO 2.5 CM" 13100_3 CDM 360 RC 13100 HCPCS outpatient 706 529.5 AETNA MCR ADV AETNA MCR ADV 550.68 78 999999999 550.68 670.7 percent of total billed charges "REPAIR, COMPLEX, TRUNK; 1.1 CM TO 2.5 CM" 13100_3 CDM 360 RC 13100 HCPCS outpatient 706 529.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 618.24 87.57 999999999 550.68 670.7 percent of total billed charges "REPAIR, COMPLEX, TRUNK; 1.1 CM TO 2.5 CM" 13100_3 CDM 360 RC 13100 HCPCS outpatient 706 529.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 600.59 85.07 999999999 550.68 670.7 percent of total billed charges "REPAIR, COMPLEX, TRUNK; 1.1 CM TO 2.5 CM" 13100_3 CDM 360 RC 13100 HCPCS outpatient 706 529.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 600.59 85.07 999999999 550.68 670.7 percent of total billed charges "REPAIR, COMPLEX, TRUNK; 1.1 CM TO 2.5 CM" 13100_3 CDM 360 RC 13100 HCPCS outpatient 706 529.5 MOLINA MCAID MOLINA MCAID 588.8 83.4 999999999 550.68 670.7 percent of total billed charges "REPAIR, COMPLEX, TRUNK; 1.1 CM TO 2.5 CM" 13100_3 CDM 360 RC 13100 HCPCS outpatient 706 529.5 MOLINA MCR ADV MOLINA MCR ADV 628.34 89 999999999 550.68 670.7 percent of total billed charges "REPAIR, COMPLEX, TRUNK; 1.1 CM TO 2.5 CM" 13100_3 CDM 360 RC 13100 HCPCS outpatient 706 529.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 628.34 89 999999999 550.68 670.7 percent of total billed charges "REPAIR, COMPLEX, TRUNK; 1.1 CM TO 2.5 CM" 13100_3 CDM 360 RC 13100 HCPCS outpatient 706 529.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 628.34 89 999999999 550.68 670.7 percent of total billed charges "REPAIR, COMPLEX, TRUNK; 1.1 CM TO 2.5 CM" 13100_3 CDM 360 RC 13100 HCPCS outpatient 706 529.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 635.4 90 999999999 550.68 670.7 percent of total billed charges "REPAIR, COMPLEX, TRUNK; 1.1 CM TO 2.5 CM" 13100_3 CDM 360 RC 13100 HCPCS outpatient 706 529.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 670.7 95 999999999 550.68 670.7 percent of total billed charges "REPAIR, COMPLEX, TRUNK; 1.1 CM TO 2.5 CM" 13100_3 CDM 360 RC 13100 HCPCS outpatient 706 529.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 670.7 95 999999999 550.68 670.7 percent of total billed charges "REPAIR, COMPLEX, TRUNK; 1.1 CM TO 2.5 CM" 13100_3 CDM 360 RC 13100 HCPCS outpatient 706 529.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 628.34 89 999999999 550.68 670.7 percent of total billed charges "REPAIR, COMPLEX, TRUNK; 1.1 CM TO 2.5 CM" 13100_3 CDM 360 RC 13100 HCPCS outpatient 706 529.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 621.28 88 999999999 550.68 670.7 percent of total billed charges "REPAIR, COMPLEX, TRUNK; 1.1 CM TO 2.5 CM" 13100_3 CDM 360 RC 13100 HCPCS outpatient 706 529.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 628.34 89 999999999 550.68 670.7 percent of total billed charges "REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM" 13101_3 CDM 360 RC 13101 HCPCS outpatient 824 618 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 741.6 999999999 642.72 782.8 case rate "REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM" 13101_3 CDM 360 RC 13101 HCPCS outpatient 824 618 AETNA MCR ADV AETNA MCR ADV 642.72 78 999999999 642.72 782.8 percent of total billed charges "REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM" 13101_3 CDM 360 RC 13101 HCPCS outpatient 824 618 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 721.58 87.57 999999999 642.72 782.8 percent of total billed charges "REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM" 13101_3 CDM 360 RC 13101 HCPCS outpatient 824 618 COORDINATED CARE MCAID COORDINATED CARE MCAID 700.98 85.07 999999999 642.72 782.8 percent of total billed charges "REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM" 13101_3 CDM 360 RC 13101 HCPCS outpatient 824 618 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 700.98 85.07 999999999 642.72 782.8 percent of total billed charges "REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM" 13101_3 CDM 360 RC 13101 HCPCS outpatient 824 618 MOLINA MCAID MOLINA MCAID 687.22 83.4 999999999 642.72 782.8 percent of total billed charges "REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM" 13101_3 CDM 360 RC 13101 HCPCS outpatient 824 618 MOLINA MCR ADV MOLINA MCR ADV 733.36 89 999999999 642.72 782.8 percent of total billed charges "REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM" 13101_3 CDM 360 RC 13101 HCPCS outpatient 824 618 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 733.36 89 999999999 642.72 782.8 percent of total billed charges "REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM" 13101_3 CDM 360 RC 13101 HCPCS outpatient 824 618 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 733.36 89 999999999 642.72 782.8 percent of total billed charges "REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM" 13101_3 CDM 360 RC 13101 HCPCS outpatient 824 618 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 741.6 90 999999999 642.72 782.8 percent of total billed charges "REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM" 13101_3 CDM 360 RC 13101 HCPCS outpatient 824 618 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 782.8 95 999999999 642.72 782.8 percent of total billed charges "REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM" 13101_3 CDM 360 RC 13101 HCPCS outpatient 824 618 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 782.8 95 999999999 642.72 782.8 percent of total billed charges "REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM" 13101_3 CDM 360 RC 13101 HCPCS outpatient 824 618 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 733.36 89 999999999 642.72 782.8 percent of total billed charges "REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM" 13101_3 CDM 360 RC 13101 HCPCS outpatient 824 618 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 725.12 88 999999999 642.72 782.8 percent of total billed charges "REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM" 13101_3 CDM 360 RC 13101 HCPCS outpatient 824 618 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 733.36 89 999999999 642.72 782.8 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 1.1 CM TO 2.5 CM" 13120_3 CDM 360 RC 13120 HCPCS outpatient 736 552 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 662.4 999999999 574.08 699.2 case rate "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 1.1 CM TO 2.5 CM" 13120_3 CDM 360 RC 13120 HCPCS outpatient 736 552 AETNA MCR ADV AETNA MCR ADV 574.08 78 999999999 574.08 699.2 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 1.1 CM TO 2.5 CM" 13120_3 CDM 360 RC 13120 HCPCS outpatient 736 552 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 644.52 87.57 999999999 574.08 699.2 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 1.1 CM TO 2.5 CM" 13120_3 CDM 360 RC 13120 HCPCS outpatient 736 552 COORDINATED CARE MCAID COORDINATED CARE MCAID 626.12 85.07 999999999 574.08 699.2 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 1.1 CM TO 2.5 CM" 13120_3 CDM 360 RC 13120 HCPCS outpatient 736 552 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 626.12 85.07 999999999 574.08 699.2 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 1.1 CM TO 2.5 CM" 13120_3 CDM 360 RC 13120 HCPCS outpatient 736 552 MOLINA MCAID MOLINA MCAID 613.82 83.4 999999999 574.08 699.2 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 1.1 CM TO 2.5 CM" 13120_3 CDM 360 RC 13120 HCPCS outpatient 736 552 MOLINA MCR ADV MOLINA MCR ADV 655.04 89 999999999 574.08 699.2 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 1.1 CM TO 2.5 CM" 13120_3 CDM 360 RC 13120 HCPCS outpatient 736 552 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 655.04 89 999999999 574.08 699.2 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 1.1 CM TO 2.5 CM" 13120_3 CDM 360 RC 13120 HCPCS outpatient 736 552 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 655.04 89 999999999 574.08 699.2 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 1.1 CM TO 2.5 CM" 13120_3 CDM 360 RC 13120 HCPCS outpatient 736 552 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 662.4 90 999999999 574.08 699.2 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 1.1 CM TO 2.5 CM" 13120_3 CDM 360 RC 13120 HCPCS outpatient 736 552 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 699.2 95 999999999 574.08 699.2 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 1.1 CM TO 2.5 CM" 13120_3 CDM 360 RC 13120 HCPCS outpatient 736 552 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 699.2 95 999999999 574.08 699.2 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 1.1 CM TO 2.5 CM" 13120_3 CDM 360 RC 13120 HCPCS outpatient 736 552 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 655.04 89 999999999 574.08 699.2 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 1.1 CM TO 2.5 CM" 13120_3 CDM 360 RC 13120 HCPCS outpatient 736 552 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 647.68 88 999999999 574.08 699.2 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 1.1 CM TO 2.5 CM" 13120_3 CDM 360 RC 13120 HCPCS outpatient 736 552 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 655.04 89 999999999 574.08 699.2 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 13121_1 CDM 360 RC 13121 HCPCS outpatient 771.96 578.97 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 694.76 999999999 602.13 733.36 case rate "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 13121_1 CDM 360 RC 13121 HCPCS outpatient 771.96 578.97 AETNA MCR ADV AETNA MCR ADV 602.13 78 999999999 602.13 733.36 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 13121_1 CDM 360 RC 13121 HCPCS outpatient 771.96 578.97 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 676.01 87.57 999999999 602.13 733.36 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 13121_1 CDM 360 RC 13121 HCPCS outpatient 771.96 578.97 COORDINATED CARE MCAID COORDINATED CARE MCAID 656.71 85.07 999999999 602.13 733.36 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 13121_1 CDM 360 RC 13121 HCPCS outpatient 771.96 578.97 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 656.71 85.07 999999999 602.13 733.36 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 13121_1 CDM 360 RC 13121 HCPCS outpatient 771.96 578.97 MOLINA MCAID MOLINA MCAID 643.81 83.4 999999999 602.13 733.36 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 13121_1 CDM 360 RC 13121 HCPCS outpatient 771.96 578.97 MOLINA MCR ADV MOLINA MCR ADV 687.04 89 999999999 602.13 733.36 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 13121_1 CDM 360 RC 13121 HCPCS outpatient 771.96 578.97 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 687.04 89 999999999 602.13 733.36 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 13121_1 CDM 360 RC 13121 HCPCS outpatient 771.96 578.97 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 687.04 89 999999999 602.13 733.36 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 13121_1 CDM 360 RC 13121 HCPCS outpatient 771.96 578.97 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 694.76 90 999999999 602.13 733.36 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 13121_1 CDM 360 RC 13121 HCPCS outpatient 771.96 578.97 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 733.36 95 999999999 602.13 733.36 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 13121_1 CDM 360 RC 13121 HCPCS outpatient 771.96 578.97 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 733.36 95 999999999 602.13 733.36 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 13121_1 CDM 360 RC 13121 HCPCS outpatient 771.96 578.97 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 687.04 89 999999999 602.13 733.36 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 13121_1 CDM 360 RC 13121 HCPCS outpatient 771.96 578.97 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 679.32 88 999999999 602.13 733.36 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 13121_1 CDM 360 RC 13121 HCPCS outpatient 771.96 578.97 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 687.04 89 999999999 602.13 733.36 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 13121_3 CDM 360 RC 13121 HCPCS outpatient 880 660 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 792 999999999 686.4 836 case rate "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 13121_3 CDM 360 RC 13121 HCPCS outpatient 880 660 AETNA MCR ADV AETNA MCR ADV 686.4 78 999999999 686.4 836 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 13121_3 CDM 360 RC 13121 HCPCS outpatient 880 660 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 770.62 87.57 999999999 686.4 836 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 13121_3 CDM 360 RC 13121 HCPCS outpatient 880 660 COORDINATED CARE MCAID COORDINATED CARE MCAID 748.62 85.07 999999999 686.4 836 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 13121_3 CDM 360 RC 13121 HCPCS outpatient 880 660 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 748.62 85.07 999999999 686.4 836 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 13121_3 CDM 360 RC 13121 HCPCS outpatient 880 660 MOLINA MCAID MOLINA MCAID 733.92 83.4 999999999 686.4 836 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 13121_3 CDM 360 RC 13121 HCPCS outpatient 880 660 MOLINA MCR ADV MOLINA MCR ADV 783.2 89 999999999 686.4 836 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 13121_3 CDM 360 RC 13121 HCPCS outpatient 880 660 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 783.2 89 999999999 686.4 836 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 13121_3 CDM 360 RC 13121 HCPCS outpatient 880 660 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 783.2 89 999999999 686.4 836 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 13121_3 CDM 360 RC 13121 HCPCS outpatient 880 660 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 792 90 999999999 686.4 836 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 13121_3 CDM 360 RC 13121 HCPCS outpatient 880 660 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 836 95 999999999 686.4 836 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 13121_3 CDM 360 RC 13121 HCPCS outpatient 880 660 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 836 95 999999999 686.4 836 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 13121_3 CDM 360 RC 13121 HCPCS outpatient 880 660 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 783.2 89 999999999 686.4 836 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 13121_3 CDM 360 RC 13121 HCPCS outpatient 880 660 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 774.4 88 999999999 686.4 836 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 13121_3 CDM 360 RC 13121 HCPCS outpatient 880 660 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 783.2 89 999999999 686.4 836 percent of total billed charges "REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 1.1 CM TO 2.5 CM" 13131_3 CDM 360 RC 13131 HCPCS outpatient 802 601.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 721.8 999999999 625.56 761.9 case rate "REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 1.1 CM TO 2.5 CM" 13131_3 CDM 360 RC 13131 HCPCS outpatient 802 601.5 AETNA MCR ADV AETNA MCR ADV 625.56 78 999999999 625.56 761.9 percent of total billed charges "REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 1.1 CM TO 2.5 CM" 13131_3 CDM 360 RC 13131 HCPCS outpatient 802 601.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 702.31 87.57 999999999 625.56 761.9 percent of total billed charges "REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 1.1 CM TO 2.5 CM" 13131_3 CDM 360 RC 13131 HCPCS outpatient 802 601.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 682.26 85.07 999999999 625.56 761.9 percent of total billed charges "REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 1.1 CM TO 2.5 CM" 13131_3 CDM 360 RC 13131 HCPCS outpatient 802 601.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 682.26 85.07 999999999 625.56 761.9 percent of total billed charges "REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 1.1 CM TO 2.5 CM" 13131_3 CDM 360 RC 13131 HCPCS outpatient 802 601.5 MOLINA MCAID MOLINA MCAID 668.87 83.4 999999999 625.56 761.9 percent of total billed charges "REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 1.1 CM TO 2.5 CM" 13131_3 CDM 360 RC 13131 HCPCS outpatient 802 601.5 MOLINA MCR ADV MOLINA MCR ADV 713.78 89 999999999 625.56 761.9 percent of total billed charges "REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 1.1 CM TO 2.5 CM" 13131_3 CDM 360 RC 13131 HCPCS outpatient 802 601.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 713.78 89 999999999 625.56 761.9 percent of total billed charges "REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 1.1 CM TO 2.5 CM" 13131_3 CDM 360 RC 13131 HCPCS outpatient 802 601.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 713.78 89 999999999 625.56 761.9 percent of total billed charges "REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 1.1 CM TO 2.5 CM" 13131_3 CDM 360 RC 13131 HCPCS outpatient 802 601.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 721.8 90 999999999 625.56 761.9 percent of total billed charges "REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 1.1 CM TO 2.5 CM" 13131_3 CDM 360 RC 13131 HCPCS outpatient 802 601.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 761.9 95 999999999 625.56 761.9 percent of total billed charges "REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 1.1 CM TO 2.5 CM" 13131_3 CDM 360 RC 13131 HCPCS outpatient 802 601.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 761.9 95 999999999 625.56 761.9 percent of total billed charges "REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 1.1 CM TO 2.5 CM" 13131_3 CDM 360 RC 13131 HCPCS outpatient 802 601.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 713.78 89 999999999 625.56 761.9 percent of total billed charges "REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 1.1 CM TO 2.5 CM" 13131_3 CDM 360 RC 13131 HCPCS outpatient 802 601.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 705.76 88 999999999 625.56 761.9 percent of total billed charges "REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 1.1 CM TO 2.5 CM" 13131_3 CDM 360 RC 13131 HCPCS outpatient 802 601.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 713.78 89 999999999 625.56 761.9 percent of total billed charges "REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 2.6 CM TO 7.5 CM" 13132_3 CDM 360 RC 13132 HCPCS outpatient 214 160.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 192.6 999999999 166.92 203.3 case rate "REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 2.6 CM TO 7.5 CM" 13132_3 CDM 360 RC 13132 HCPCS outpatient 214 160.5 AETNA MCR ADV AETNA MCR ADV 166.92 78 999999999 166.92 203.3 percent of total billed charges "REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 2.6 CM TO 7.5 CM" 13132_3 CDM 360 RC 13132 HCPCS outpatient 214 160.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 187.4 87.57 999999999 166.92 203.3 percent of total billed charges "REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 2.6 CM TO 7.5 CM" 13132_3 CDM 360 RC 13132 HCPCS outpatient 214 160.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 182.05 85.07 999999999 166.92 203.3 percent of total billed charges "REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 2.6 CM TO 7.5 CM" 13132_3 CDM 360 RC 13132 HCPCS outpatient 214 160.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 182.05 85.07 999999999 166.92 203.3 percent of total billed charges "REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 2.6 CM TO 7.5 CM" 13132_3 CDM 360 RC 13132 HCPCS outpatient 214 160.5 MOLINA MCAID MOLINA MCAID 178.48 83.4 999999999 166.92 203.3 percent of total billed charges "REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 2.6 CM TO 7.5 CM" 13132_3 CDM 360 RC 13132 HCPCS outpatient 214 160.5 MOLINA MCR ADV MOLINA MCR ADV 190.46 89 999999999 166.92 203.3 percent of total billed charges "REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 2.6 CM TO 7.5 CM" 13132_3 CDM 360 RC 13132 HCPCS outpatient 214 160.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 190.46 89 999999999 166.92 203.3 percent of total billed charges "REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 2.6 CM TO 7.5 CM" 13132_3 CDM 360 RC 13132 HCPCS outpatient 214 160.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 190.46 89 999999999 166.92 203.3 percent of total billed charges "REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 2.6 CM TO 7.5 CM" 13132_3 CDM 360 RC 13132 HCPCS outpatient 214 160.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 192.6 90 999999999 166.92 203.3 percent of total billed charges "REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 2.6 CM TO 7.5 CM" 13132_3 CDM 360 RC 13132 HCPCS outpatient 214 160.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 203.3 95 999999999 166.92 203.3 percent of total billed charges "REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 2.6 CM TO 7.5 CM" 13132_3 CDM 360 RC 13132 HCPCS outpatient 214 160.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 203.3 95 999999999 166.92 203.3 percent of total billed charges "REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 2.6 CM TO 7.5 CM" 13132_3 CDM 360 RC 13132 HCPCS outpatient 214 160.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 190.46 89 999999999 166.92 203.3 percent of total billed charges "REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 2.6 CM TO 7.5 CM" 13132_3 CDM 360 RC 13132 HCPCS outpatient 214 160.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 188.32 88 999999999 166.92 203.3 percent of total billed charges "REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 2.6 CM TO 7.5 CM" 13132_3 CDM 360 RC 13132 HCPCS outpatient 214 160.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 190.46 89 999999999 166.92 203.3 percent of total billed charges "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 1.1 CM TO 2.5 CM" 13151_3 CDM 360 RC 13151 HCPCS outpatient 872 654 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 784.8 999999999 680.16 828.4 case rate "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 1.1 CM TO 2.5 CM" 13151_3 CDM 360 RC 13151 HCPCS outpatient 872 654 AETNA MCR ADV AETNA MCR ADV 680.16 78 999999999 680.16 828.4 percent of total billed charges "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 1.1 CM TO 2.5 CM" 13151_3 CDM 360 RC 13151 HCPCS outpatient 872 654 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 763.61 87.57 999999999 680.16 828.4 percent of total billed charges "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 1.1 CM TO 2.5 CM" 13151_3 CDM 360 RC 13151 HCPCS outpatient 872 654 COORDINATED CARE MCAID COORDINATED CARE MCAID 741.81 85.07 999999999 680.16 828.4 percent of total billed charges "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 1.1 CM TO 2.5 CM" 13151_3 CDM 360 RC 13151 HCPCS outpatient 872 654 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 741.81 85.07 999999999 680.16 828.4 percent of total billed charges "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 1.1 CM TO 2.5 CM" 13151_3 CDM 360 RC 13151 HCPCS outpatient 872 654 MOLINA MCAID MOLINA MCAID 727.25 83.4 999999999 680.16 828.4 percent of total billed charges "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 1.1 CM TO 2.5 CM" 13151_3 CDM 360 RC 13151 HCPCS outpatient 872 654 MOLINA MCR ADV MOLINA MCR ADV 776.08 89 999999999 680.16 828.4 percent of total billed charges "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 1.1 CM TO 2.5 CM" 13151_3 CDM 360 RC 13151 HCPCS outpatient 872 654 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 776.08 89 999999999 680.16 828.4 percent of total billed charges "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 1.1 CM TO 2.5 CM" 13151_3 CDM 360 RC 13151 HCPCS outpatient 872 654 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 776.08 89 999999999 680.16 828.4 percent of total billed charges "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 1.1 CM TO 2.5 CM" 13151_3 CDM 360 RC 13151 HCPCS outpatient 872 654 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 784.8 90 999999999 680.16 828.4 percent of total billed charges "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 1.1 CM TO 2.5 CM" 13151_3 CDM 360 RC 13151 HCPCS outpatient 872 654 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 828.4 95 999999999 680.16 828.4 percent of total billed charges "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 1.1 CM TO 2.5 CM" 13151_3 CDM 360 RC 13151 HCPCS outpatient 872 654 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 828.4 95 999999999 680.16 828.4 percent of total billed charges "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 1.1 CM TO 2.5 CM" 13151_3 CDM 360 RC 13151 HCPCS outpatient 872 654 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 776.08 89 999999999 680.16 828.4 percent of total billed charges "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 1.1 CM TO 2.5 CM" 13151_3 CDM 360 RC 13151 HCPCS outpatient 872 654 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 767.36 88 999999999 680.16 828.4 percent of total billed charges "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 1.1 CM TO 2.5 CM" 13151_3 CDM 360 RC 13151 HCPCS outpatient 872 654 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 776.08 89 999999999 680.16 828.4 percent of total billed charges "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 2.6 CM TO 7.5 CM" 13152_3 CDM 360 RC 13152 HCPCS outpatient 212 159 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 190.8 999999999 165.36 201.4 case rate "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 2.6 CM TO 7.5 CM" 13152_3 CDM 360 RC 13152 HCPCS outpatient 212 159 AETNA MCR ADV AETNA MCR ADV 165.36 78 999999999 165.36 201.4 percent of total billed charges "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 2.6 CM TO 7.5 CM" 13152_3 CDM 360 RC 13152 HCPCS outpatient 212 159 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 185.65 87.57 999999999 165.36 201.4 percent of total billed charges "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 2.6 CM TO 7.5 CM" 13152_3 CDM 360 RC 13152 HCPCS outpatient 212 159 COORDINATED CARE MCAID COORDINATED CARE MCAID 180.35 85.07 999999999 165.36 201.4 percent of total billed charges "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 2.6 CM TO 7.5 CM" 13152_3 CDM 360 RC 13152 HCPCS outpatient 212 159 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 180.35 85.07 999999999 165.36 201.4 percent of total billed charges "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 2.6 CM TO 7.5 CM" 13152_3 CDM 360 RC 13152 HCPCS outpatient 212 159 MOLINA MCAID MOLINA MCAID 176.81 83.4 999999999 165.36 201.4 percent of total billed charges "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 2.6 CM TO 7.5 CM" 13152_3 CDM 360 RC 13152 HCPCS outpatient 212 159 MOLINA MCR ADV MOLINA MCR ADV 188.68 89 999999999 165.36 201.4 percent of total billed charges "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 2.6 CM TO 7.5 CM" 13152_3 CDM 360 RC 13152 HCPCS outpatient 212 159 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 188.68 89 999999999 165.36 201.4 percent of total billed charges "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 2.6 CM TO 7.5 CM" 13152_3 CDM 360 RC 13152 HCPCS outpatient 212 159 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 188.68 89 999999999 165.36 201.4 percent of total billed charges "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 2.6 CM TO 7.5 CM" 13152_3 CDM 360 RC 13152 HCPCS outpatient 212 159 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 190.8 90 999999999 165.36 201.4 percent of total billed charges "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 2.6 CM TO 7.5 CM" 13152_3 CDM 360 RC 13152 HCPCS outpatient 212 159 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 201.4 95 999999999 165.36 201.4 percent of total billed charges "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 2.6 CM TO 7.5 CM" 13152_3 CDM 360 RC 13152 HCPCS outpatient 212 159 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 201.4 95 999999999 165.36 201.4 percent of total billed charges "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 2.6 CM TO 7.5 CM" 13152_3 CDM 360 RC 13152 HCPCS outpatient 212 159 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 188.68 89 999999999 165.36 201.4 percent of total billed charges "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 2.6 CM TO 7.5 CM" 13152_3 CDM 360 RC 13152 HCPCS outpatient 212 159 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 186.56 88 999999999 165.36 201.4 percent of total billed charges "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 2.6 CM TO 7.5 CM" 13152_3 CDM 360 RC 13152 HCPCS outpatient 212 159 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 188.68 89 999999999 165.36 201.4 percent of total billed charges "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; EACH ADDITIONAL 5 CM OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 13153_3 CDM 360 RC 13153 HCPCS outpatient 376 282 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 338.4 999999999 293.28 357.2 case rate "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; EACH ADDITIONAL 5 CM OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 13153_3 CDM 360 RC 13153 HCPCS outpatient 376 282 AETNA MCR ADV AETNA MCR ADV 293.28 78 999999999 293.28 357.2 percent of total billed charges "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; EACH ADDITIONAL 5 CM OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 13153_3 CDM 360 RC 13153 HCPCS outpatient 376 282 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 329.26 87.57 999999999 293.28 357.2 percent of total billed charges "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; EACH ADDITIONAL 5 CM OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 13153_3 CDM 360 RC 13153 HCPCS outpatient 376 282 COORDINATED CARE MCAID COORDINATED CARE MCAID 319.86 85.07 999999999 293.28 357.2 percent of total billed charges "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; EACH ADDITIONAL 5 CM OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 13153_3 CDM 360 RC 13153 HCPCS outpatient 376 282 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 319.86 85.07 999999999 293.28 357.2 percent of total billed charges "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; EACH ADDITIONAL 5 CM OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 13153_3 CDM 360 RC 13153 HCPCS outpatient 376 282 MOLINA MCAID MOLINA MCAID 313.58 83.4 999999999 293.28 357.2 percent of total billed charges "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; EACH ADDITIONAL 5 CM OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 13153_3 CDM 360 RC 13153 HCPCS outpatient 376 282 MOLINA MCR ADV MOLINA MCR ADV 334.64 89 999999999 293.28 357.2 percent of total billed charges "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; EACH ADDITIONAL 5 CM OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 13153_3 CDM 360 RC 13153 HCPCS outpatient 376 282 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 334.64 89 999999999 293.28 357.2 percent of total billed charges "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; EACH ADDITIONAL 5 CM OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 13153_3 CDM 360 RC 13153 HCPCS outpatient 376 282 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 334.64 89 999999999 293.28 357.2 percent of total billed charges "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; EACH ADDITIONAL 5 CM OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 13153_3 CDM 360 RC 13153 HCPCS outpatient 376 282 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 338.4 90 999999999 293.28 357.2 percent of total billed charges "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; EACH ADDITIONAL 5 CM OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 13153_3 CDM 360 RC 13153 HCPCS outpatient 376 282 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 357.2 95 999999999 293.28 357.2 percent of total billed charges "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; EACH ADDITIONAL 5 CM OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 13153_3 CDM 360 RC 13153 HCPCS outpatient 376 282 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 357.2 95 999999999 293.28 357.2 percent of total billed charges "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; EACH ADDITIONAL 5 CM OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 13153_3 CDM 360 RC 13153 HCPCS outpatient 376 282 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 334.64 89 999999999 293.28 357.2 percent of total billed charges "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; EACH ADDITIONAL 5 CM OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 13153_3 CDM 360 RC 13153 HCPCS outpatient 376 282 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 330.88 88 999999999 293.28 357.2 percent of total billed charges "REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; EACH ADDITIONAL 5 CM OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 13153_3 CDM 360 RC 13153 HCPCS outpatient 376 282 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 334.64 89 999999999 293.28 357.2 percent of total billed charges "INITIAL TREATMENT, FIRST DEGREE BURN, WHEN NO MORE THAN LOCAL TREATMENT IS REQUIRED" 16000_3 CDM 360 RC 16000 HCPCS outpatient 154 115.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 138.6 999999999 120.12 146.3 case rate "INITIAL TREATMENT, FIRST DEGREE BURN, WHEN NO MORE THAN LOCAL TREATMENT IS REQUIRED" 16000_3 CDM 360 RC 16000 HCPCS outpatient 154 115.5 AETNA MCR ADV AETNA MCR ADV 120.12 78 999999999 120.12 146.3 percent of total billed charges "INITIAL TREATMENT, FIRST DEGREE BURN, WHEN NO MORE THAN LOCAL TREATMENT IS REQUIRED" 16000_3 CDM 360 RC 16000 HCPCS outpatient 154 115.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 134.86 87.57 999999999 120.12 146.3 percent of total billed charges "INITIAL TREATMENT, FIRST DEGREE BURN, WHEN NO MORE THAN LOCAL TREATMENT IS REQUIRED" 16000_3 CDM 360 RC 16000 HCPCS outpatient 154 115.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 131.01 85.07 999999999 120.12 146.3 percent of total billed charges "INITIAL TREATMENT, FIRST DEGREE BURN, WHEN NO MORE THAN LOCAL TREATMENT IS REQUIRED" 16000_3 CDM 360 RC 16000 HCPCS outpatient 154 115.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 131.01 85.07 999999999 120.12 146.3 percent of total billed charges "INITIAL TREATMENT, FIRST DEGREE BURN, WHEN NO MORE THAN LOCAL TREATMENT IS REQUIRED" 16000_3 CDM 360 RC 16000 HCPCS outpatient 154 115.5 MOLINA MCAID MOLINA MCAID 128.44 83.4 999999999 120.12 146.3 percent of total billed charges "INITIAL TREATMENT, FIRST DEGREE BURN, WHEN NO MORE THAN LOCAL TREATMENT IS REQUIRED" 16000_3 CDM 360 RC 16000 HCPCS outpatient 154 115.5 MOLINA MCR ADV MOLINA MCR ADV 137.06 89 999999999 120.12 146.3 percent of total billed charges "INITIAL TREATMENT, FIRST DEGREE BURN, WHEN NO MORE THAN LOCAL TREATMENT IS REQUIRED" 16000_3 CDM 360 RC 16000 HCPCS outpatient 154 115.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 137.06 89 999999999 120.12 146.3 percent of total billed charges "INITIAL TREATMENT, FIRST DEGREE BURN, WHEN NO MORE THAN LOCAL TREATMENT IS REQUIRED" 16000_3 CDM 360 RC 16000 HCPCS outpatient 154 115.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 137.06 89 999999999 120.12 146.3 percent of total billed charges "INITIAL TREATMENT, FIRST DEGREE BURN, WHEN NO MORE THAN LOCAL TREATMENT IS REQUIRED" 16000_3 CDM 360 RC 16000 HCPCS outpatient 154 115.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 138.6 90 999999999 120.12 146.3 percent of total billed charges "INITIAL TREATMENT, FIRST DEGREE BURN, WHEN NO MORE THAN LOCAL TREATMENT IS REQUIRED" 16000_3 CDM 360 RC 16000 HCPCS outpatient 154 115.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 146.3 95 999999999 120.12 146.3 percent of total billed charges "INITIAL TREATMENT, FIRST DEGREE BURN, WHEN NO MORE THAN LOCAL TREATMENT IS REQUIRED" 16000_3 CDM 360 RC 16000 HCPCS outpatient 154 115.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 146.3 95 999999999 120.12 146.3 percent of total billed charges "INITIAL TREATMENT, FIRST DEGREE BURN, WHEN NO MORE THAN LOCAL TREATMENT IS REQUIRED" 16000_3 CDM 360 RC 16000 HCPCS outpatient 154 115.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 137.06 89 999999999 120.12 146.3 percent of total billed charges "INITIAL TREATMENT, FIRST DEGREE BURN, WHEN NO MORE THAN LOCAL TREATMENT IS REQUIRED" 16000_3 CDM 360 RC 16000 HCPCS outpatient 154 115.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 135.52 88 999999999 120.12 146.3 percent of total billed charges "INITIAL TREATMENT, FIRST DEGREE BURN, WHEN NO MORE THAN LOCAL TREATMENT IS REQUIRED" 16000_3 CDM 360 RC 16000 HCPCS outpatient 154 115.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 137.06 89 999999999 120.12 146.3 percent of total billed charges ROOM & BOARD - OTHER - GENERAL CLASSIFICATION 1600000003_1 CDM 160 RC inpatient 300 225 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 270 90 999999999 264 10619 percent of total billed charges ROOM & BOARD - OTHER - GENERAL CLASSIFICATION 1600000003_1 CDM 160 RC inpatient 300 225 AETNA MCR ADV AETNA MCR ADV 10619 999999999 264 10619 per diem ROOM & BOARD - OTHER - GENERAL CLASSIFICATION 1600000003_1 CDM 160 RC inpatient 300 225 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 559.62 186.54 999999999 264 10619 percent of total billed charges ROOM & BOARD - OTHER - GENERAL CLASSIFICATION 1600000003_1 CDM 160 RC inpatient 300 225 COORDINATED CARE MCAID COORDINATED CARE MCAID 543.63 181.21 999999999 264 10619 percent of total billed charges ROOM & BOARD - OTHER - GENERAL CLASSIFICATION 1600000003_1 CDM 160 RC inpatient 300 225 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 543.63 181.21 999999999 264 10619 percent of total billed charges ROOM & BOARD - OTHER - GENERAL CLASSIFICATION 1600000003_1 CDM 160 RC inpatient 300 225 MOLINA MCAID MOLINA MCAID 532.98 177.66 999999999 264 10619 percent of total billed charges ROOM & BOARD - OTHER - GENERAL CLASSIFICATION 1600000003_1 CDM 160 RC inpatient 300 225 MOLINA MCR ADV MOLINA MCR ADV 8243 999999999 264 10619 per diem ROOM & BOARD - OTHER - GENERAL CLASSIFICATION 1600000003_1 CDM 160 RC inpatient 300 225 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 8243 999999999 264 10619 per diem ROOM & BOARD - OTHER - GENERAL CLASSIFICATION 1600000003_1 CDM 160 RC inpatient 300 225 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 8243 999999999 264 10619 per diem ROOM & BOARD - OTHER - GENERAL CLASSIFICATION 1600000003_1 CDM 160 RC inpatient 300 225 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 270 90 999999999 264 10619 percent of total billed charges ROOM & BOARD - OTHER - GENERAL CLASSIFICATION 1600000003_1 CDM 160 RC inpatient 300 225 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 285 95 999999999 264 10619 percent of total billed charges ROOM & BOARD - OTHER - GENERAL CLASSIFICATION 1600000003_1 CDM 160 RC inpatient 300 225 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 285 95 999999999 264 10619 percent of total billed charges ROOM & BOARD - OTHER - GENERAL CLASSIFICATION 1600000003_1 CDM 160 RC inpatient 300 225 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 8243 999999999 264 10619 per diem ROOM & BOARD - OTHER - GENERAL CLASSIFICATION 1600000003_1 CDM 160 RC inpatient 300 225 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 264 88 999999999 264 10619 percent of total billed charges ROOM & BOARD - OTHER - GENERAL CLASSIFICATION 1600000003_1 CDM 160 RC inpatient 300 225 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 7006.55 999999999 264 10619 per diem "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_1 CDM 360 RC 16020 HCPCS outpatient 226 169.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 203.4 999999999 176.28 214.7 case rate "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_1 CDM 360 RC 16020 HCPCS outpatient 226 169.5 AETNA MCR ADV AETNA MCR ADV 176.28 78 999999999 176.28 214.7 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_1 CDM 360 RC 16020 HCPCS outpatient 226 169.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 197.91 87.57 999999999 176.28 214.7 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_1 CDM 360 RC 16020 HCPCS outpatient 226 169.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 192.26 85.07 999999999 176.28 214.7 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_1 CDM 360 RC 16020 HCPCS outpatient 226 169.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 192.26 85.07 999999999 176.28 214.7 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_1 CDM 360 RC 16020 HCPCS outpatient 226 169.5 MOLINA MCAID MOLINA MCAID 188.48 83.4 999999999 176.28 214.7 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_1 CDM 360 RC 16020 HCPCS outpatient 226 169.5 MOLINA MCR ADV MOLINA MCR ADV 201.14 89 999999999 176.28 214.7 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_1 CDM 360 RC 16020 HCPCS outpatient 226 169.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 201.14 89 999999999 176.28 214.7 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_1 CDM 360 RC 16020 HCPCS outpatient 226 169.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 201.14 89 999999999 176.28 214.7 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_1 CDM 360 RC 16020 HCPCS outpatient 226 169.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 203.4 90 999999999 176.28 214.7 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_1 CDM 360 RC 16020 HCPCS outpatient 226 169.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 214.7 95 999999999 176.28 214.7 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_1 CDM 360 RC 16020 HCPCS outpatient 226 169.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 214.7 95 999999999 176.28 214.7 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_1 CDM 360 RC 16020 HCPCS outpatient 226 169.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 201.14 89 999999999 176.28 214.7 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_1 CDM 360 RC 16020 HCPCS outpatient 226 169.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 198.88 88 999999999 176.28 214.7 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_1 CDM 360 RC 16020 HCPCS outpatient 226 169.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 201.14 89 999999999 176.28 214.7 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_2 CDM 360 RC 16020 HCPCS outpatient 226 169.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 203.4 999999999 176.28 214.7 case rate "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_2 CDM 360 RC 16020 HCPCS outpatient 226 169.5 AETNA MCR ADV AETNA MCR ADV 176.28 78 999999999 176.28 214.7 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_2 CDM 360 RC 16020 HCPCS outpatient 226 169.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 197.91 87.57 999999999 176.28 214.7 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_2 CDM 360 RC 16020 HCPCS outpatient 226 169.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 192.26 85.07 999999999 176.28 214.7 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_2 CDM 360 RC 16020 HCPCS outpatient 226 169.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 192.26 85.07 999999999 176.28 214.7 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_2 CDM 360 RC 16020 HCPCS outpatient 226 169.5 MOLINA MCAID MOLINA MCAID 188.48 83.4 999999999 176.28 214.7 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_2 CDM 360 RC 16020 HCPCS outpatient 226 169.5 MOLINA MCR ADV MOLINA MCR ADV 201.14 89 999999999 176.28 214.7 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_2 CDM 360 RC 16020 HCPCS outpatient 226 169.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 201.14 89 999999999 176.28 214.7 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_2 CDM 360 RC 16020 HCPCS outpatient 226 169.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 201.14 89 999999999 176.28 214.7 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_2 CDM 360 RC 16020 HCPCS outpatient 226 169.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 203.4 90 999999999 176.28 214.7 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_2 CDM 360 RC 16020 HCPCS outpatient 226 169.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 214.7 95 999999999 176.28 214.7 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_2 CDM 360 RC 16020 HCPCS outpatient 226 169.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 214.7 95 999999999 176.28 214.7 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_2 CDM 360 RC 16020 HCPCS outpatient 226 169.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 201.14 89 999999999 176.28 214.7 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_2 CDM 360 RC 16020 HCPCS outpatient 226 169.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 198.88 88 999999999 176.28 214.7 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_2 CDM 360 RC 16020 HCPCS outpatient 226 169.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 201.14 89 999999999 176.28 214.7 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_3 CDM 360 RC 16020 HCPCS outpatient 173 129.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 155.7 999999999 134.94 164.35 case rate "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_3 CDM 360 RC 16020 HCPCS outpatient 173 129.75 AETNA MCR ADV AETNA MCR ADV 134.94 78 999999999 134.94 164.35 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_3 CDM 360 RC 16020 HCPCS outpatient 173 129.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 151.5 87.57 999999999 134.94 164.35 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_3 CDM 360 RC 16020 HCPCS outpatient 173 129.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 147.17 85.07 999999999 134.94 164.35 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_3 CDM 360 RC 16020 HCPCS outpatient 173 129.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 147.17 85.07 999999999 134.94 164.35 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_3 CDM 360 RC 16020 HCPCS outpatient 173 129.75 MOLINA MCAID MOLINA MCAID 144.28 83.4 999999999 134.94 164.35 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_3 CDM 360 RC 16020 HCPCS outpatient 173 129.75 MOLINA MCR ADV MOLINA MCR ADV 153.97 89 999999999 134.94 164.35 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_3 CDM 360 RC 16020 HCPCS outpatient 173 129.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 153.97 89 999999999 134.94 164.35 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_3 CDM 360 RC 16020 HCPCS outpatient 173 129.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 153.97 89 999999999 134.94 164.35 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_3 CDM 360 RC 16020 HCPCS outpatient 173 129.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 155.7 90 999999999 134.94 164.35 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_3 CDM 360 RC 16020 HCPCS outpatient 173 129.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 164.35 95 999999999 134.94 164.35 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_3 CDM 360 RC 16020 HCPCS outpatient 173 129.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 164.35 95 999999999 134.94 164.35 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_3 CDM 360 RC 16020 HCPCS outpatient 173 129.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 153.97 89 999999999 134.94 164.35 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_3 CDM 360 RC 16020 HCPCS outpatient 173 129.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 152.24 88 999999999 134.94 164.35 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 16020_3 CDM 360 RC 16020 HCPCS outpatient 173 129.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 153.97 89 999999999 134.94 164.35 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; MEDIUM (EG, WHOLE FACE OR WHOLE EXTREMITY, OR 5% TO 10% TOTAL BODY SURFACE AREA)" 16025_3 CDM 360 RC 16025 HCPCS outpatient 320 240 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 288 999999999 249.6 304 case rate "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; MEDIUM (EG, WHOLE FACE OR WHOLE EXTREMITY, OR 5% TO 10% TOTAL BODY SURFACE AREA)" 16025_3 CDM 360 RC 16025 HCPCS outpatient 320 240 AETNA MCR ADV AETNA MCR ADV 249.6 78 999999999 249.6 304 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; MEDIUM (EG, WHOLE FACE OR WHOLE EXTREMITY, OR 5% TO 10% TOTAL BODY SURFACE AREA)" 16025_3 CDM 360 RC 16025 HCPCS outpatient 320 240 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 280.22 87.57 999999999 249.6 304 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; MEDIUM (EG, WHOLE FACE OR WHOLE EXTREMITY, OR 5% TO 10% TOTAL BODY SURFACE AREA)" 16025_3 CDM 360 RC 16025 HCPCS outpatient 320 240 COORDINATED CARE MCAID COORDINATED CARE MCAID 272.22 85.07 999999999 249.6 304 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; MEDIUM (EG, WHOLE FACE OR WHOLE EXTREMITY, OR 5% TO 10% TOTAL BODY SURFACE AREA)" 16025_3 CDM 360 RC 16025 HCPCS outpatient 320 240 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 272.22 85.07 999999999 249.6 304 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; MEDIUM (EG, WHOLE FACE OR WHOLE EXTREMITY, OR 5% TO 10% TOTAL BODY SURFACE AREA)" 16025_3 CDM 360 RC 16025 HCPCS outpatient 320 240 MOLINA MCAID MOLINA MCAID 266.88 83.4 999999999 249.6 304 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; MEDIUM (EG, WHOLE FACE OR WHOLE EXTREMITY, OR 5% TO 10% TOTAL BODY SURFACE AREA)" 16025_3 CDM 360 RC 16025 HCPCS outpatient 320 240 MOLINA MCR ADV MOLINA MCR ADV 284.8 89 999999999 249.6 304 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; MEDIUM (EG, WHOLE FACE OR WHOLE EXTREMITY, OR 5% TO 10% TOTAL BODY SURFACE AREA)" 16025_3 CDM 360 RC 16025 HCPCS outpatient 320 240 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 284.8 89 999999999 249.6 304 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; MEDIUM (EG, WHOLE FACE OR WHOLE EXTREMITY, OR 5% TO 10% TOTAL BODY SURFACE AREA)" 16025_3 CDM 360 RC 16025 HCPCS outpatient 320 240 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 284.8 89 999999999 249.6 304 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; MEDIUM (EG, WHOLE FACE OR WHOLE EXTREMITY, OR 5% TO 10% TOTAL BODY SURFACE AREA)" 16025_3 CDM 360 RC 16025 HCPCS outpatient 320 240 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 288 90 999999999 249.6 304 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; MEDIUM (EG, WHOLE FACE OR WHOLE EXTREMITY, OR 5% TO 10% TOTAL BODY SURFACE AREA)" 16025_3 CDM 360 RC 16025 HCPCS outpatient 320 240 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 304 95 999999999 249.6 304 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; MEDIUM (EG, WHOLE FACE OR WHOLE EXTREMITY, OR 5% TO 10% TOTAL BODY SURFACE AREA)" 16025_3 CDM 360 RC 16025 HCPCS outpatient 320 240 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 304 95 999999999 249.6 304 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; MEDIUM (EG, WHOLE FACE OR WHOLE EXTREMITY, OR 5% TO 10% TOTAL BODY SURFACE AREA)" 16025_3 CDM 360 RC 16025 HCPCS outpatient 320 240 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 284.8 89 999999999 249.6 304 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; MEDIUM (EG, WHOLE FACE OR WHOLE EXTREMITY, OR 5% TO 10% TOTAL BODY SURFACE AREA)" 16025_3 CDM 360 RC 16025 HCPCS outpatient 320 240 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 281.6 88 999999999 249.6 304 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; MEDIUM (EG, WHOLE FACE OR WHOLE EXTREMITY, OR 5% TO 10% TOTAL BODY SURFACE AREA)" 16025_3 CDM 360 RC 16025 HCPCS outpatient 320 240 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 284.8 89 999999999 249.6 304 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; LARGE (EG, MORE THAN 1 EXTREMITY, OR GREATER THAN 10% TOTAL BODY SURFACE AREA)" 16030_3 CDM 360 RC 16030 HCPCS outpatient 402 301.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 361.8 999999999 313.56 381.9 case rate "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; LARGE (EG, MORE THAN 1 EXTREMITY, OR GREATER THAN 10% TOTAL BODY SURFACE AREA)" 16030_3 CDM 360 RC 16030 HCPCS outpatient 402 301.5 AETNA MCR ADV AETNA MCR ADV 313.56 78 999999999 313.56 381.9 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; LARGE (EG, MORE THAN 1 EXTREMITY, OR GREATER THAN 10% TOTAL BODY SURFACE AREA)" 16030_3 CDM 360 RC 16030 HCPCS outpatient 402 301.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 352.03 87.57 999999999 313.56 381.9 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; LARGE (EG, MORE THAN 1 EXTREMITY, OR GREATER THAN 10% TOTAL BODY SURFACE AREA)" 16030_3 CDM 360 RC 16030 HCPCS outpatient 402 301.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 341.98 85.07 999999999 313.56 381.9 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; LARGE (EG, MORE THAN 1 EXTREMITY, OR GREATER THAN 10% TOTAL BODY SURFACE AREA)" 16030_3 CDM 360 RC 16030 HCPCS outpatient 402 301.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 341.98 85.07 999999999 313.56 381.9 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; LARGE (EG, MORE THAN 1 EXTREMITY, OR GREATER THAN 10% TOTAL BODY SURFACE AREA)" 16030_3 CDM 360 RC 16030 HCPCS outpatient 402 301.5 MOLINA MCAID MOLINA MCAID 335.27 83.4 999999999 313.56 381.9 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; LARGE (EG, MORE THAN 1 EXTREMITY, OR GREATER THAN 10% TOTAL BODY SURFACE AREA)" 16030_3 CDM 360 RC 16030 HCPCS outpatient 402 301.5 MOLINA MCR ADV MOLINA MCR ADV 357.78 89 999999999 313.56 381.9 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; LARGE (EG, MORE THAN 1 EXTREMITY, OR GREATER THAN 10% TOTAL BODY SURFACE AREA)" 16030_3 CDM 360 RC 16030 HCPCS outpatient 402 301.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 357.78 89 999999999 313.56 381.9 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; LARGE (EG, MORE THAN 1 EXTREMITY, OR GREATER THAN 10% TOTAL BODY SURFACE AREA)" 16030_3 CDM 360 RC 16030 HCPCS outpatient 402 301.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 357.78 89 999999999 313.56 381.9 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; LARGE (EG, MORE THAN 1 EXTREMITY, OR GREATER THAN 10% TOTAL BODY SURFACE AREA)" 16030_3 CDM 360 RC 16030 HCPCS outpatient 402 301.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 361.8 90 999999999 313.56 381.9 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; LARGE (EG, MORE THAN 1 EXTREMITY, OR GREATER THAN 10% TOTAL BODY SURFACE AREA)" 16030_3 CDM 360 RC 16030 HCPCS outpatient 402 301.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 381.9 95 999999999 313.56 381.9 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; LARGE (EG, MORE THAN 1 EXTREMITY, OR GREATER THAN 10% TOTAL BODY SURFACE AREA)" 16030_3 CDM 360 RC 16030 HCPCS outpatient 402 301.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 381.9 95 999999999 313.56 381.9 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; LARGE (EG, MORE THAN 1 EXTREMITY, OR GREATER THAN 10% TOTAL BODY SURFACE AREA)" 16030_3 CDM 360 RC 16030 HCPCS outpatient 402 301.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 357.78 89 999999999 313.56 381.9 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; LARGE (EG, MORE THAN 1 EXTREMITY, OR GREATER THAN 10% TOTAL BODY SURFACE AREA)" 16030_3 CDM 360 RC 16030 HCPCS outpatient 402 301.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 353.76 88 999999999 313.56 381.9 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; LARGE (EG, MORE THAN 1 EXTREMITY, OR GREATER THAN 10% TOTAL BODY SURFACE AREA)" 16030_3 CDM 360 RC 16030 HCPCS outpatient 402 301.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 357.78 89 999999999 313.56 381.9 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES); FIRST LESION" 17000_3 CDM 360 RC 17000 HCPCS outpatient 138 103.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 124.2 999999999 107.64 131.1 case rate "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES); FIRST LESION" 17000_3 CDM 360 RC 17000 HCPCS outpatient 138 103.5 AETNA MCR ADV AETNA MCR ADV 107.64 78 999999999 107.64 131.1 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES); FIRST LESION" 17000_3 CDM 360 RC 17000 HCPCS outpatient 138 103.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 120.85 87.57 999999999 107.64 131.1 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES); FIRST LESION" 17000_3 CDM 360 RC 17000 HCPCS outpatient 138 103.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 117.4 85.07 999999999 107.64 131.1 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES); FIRST LESION" 17000_3 CDM 360 RC 17000 HCPCS outpatient 138 103.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 117.4 85.07 999999999 107.64 131.1 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES); FIRST LESION" 17000_3 CDM 360 RC 17000 HCPCS outpatient 138 103.5 MOLINA MCAID MOLINA MCAID 115.09 83.4 999999999 107.64 131.1 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES); FIRST LESION" 17000_3 CDM 360 RC 17000 HCPCS outpatient 138 103.5 MOLINA MCR ADV MOLINA MCR ADV 122.82 89 999999999 107.64 131.1 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES); FIRST LESION" 17000_3 CDM 360 RC 17000 HCPCS outpatient 138 103.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 122.82 89 999999999 107.64 131.1 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES); FIRST LESION" 17000_3 CDM 360 RC 17000 HCPCS outpatient 138 103.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 122.82 89 999999999 107.64 131.1 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES); FIRST LESION" 17000_3 CDM 360 RC 17000 HCPCS outpatient 138 103.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 124.2 90 999999999 107.64 131.1 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES); FIRST LESION" 17000_3 CDM 360 RC 17000 HCPCS outpatient 138 103.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 131.1 95 999999999 107.64 131.1 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES); FIRST LESION" 17000_3 CDM 360 RC 17000 HCPCS outpatient 138 103.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 131.1 95 999999999 107.64 131.1 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES); FIRST LESION" 17000_3 CDM 360 RC 17000 HCPCS outpatient 138 103.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 122.82 89 999999999 107.64 131.1 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES); FIRST LESION" 17000_3 CDM 360 RC 17000 HCPCS outpatient 138 103.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 121.44 88 999999999 107.64 131.1 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES); FIRST LESION" 17000_3 CDM 360 RC 17000 HCPCS outpatient 138 103.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 122.82 89 999999999 107.64 131.1 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES); SECOND THROUGH 14 LESIONS, EACH (LIST SEPARATELY IN ADDITION TO CODE FOR FIRST LESION)" 17003_3 CDM 360 RC 17003 HCPCS outpatient 14 10.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 12.6 999999999 10.92 13.3 case rate "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES); SECOND THROUGH 14 LESIONS, EACH (LIST SEPARATELY IN ADDITION TO CODE FOR FIRST LESION)" 17003_3 CDM 360 RC 17003 HCPCS outpatient 14 10.5 AETNA MCR ADV AETNA MCR ADV 10.92 78 999999999 10.92 13.3 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES); SECOND THROUGH 14 LESIONS, EACH (LIST SEPARATELY IN ADDITION TO CODE FOR FIRST LESION)" 17003_3 CDM 360 RC 17003 HCPCS outpatient 14 10.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 12.26 87.57 999999999 10.92 13.3 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES); SECOND THROUGH 14 LESIONS, EACH (LIST SEPARATELY IN ADDITION TO CODE FOR FIRST LESION)" 17003_3 CDM 360 RC 17003 HCPCS outpatient 14 10.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 11.91 85.07 999999999 10.92 13.3 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES); SECOND THROUGH 14 LESIONS, EACH (LIST SEPARATELY IN ADDITION TO CODE FOR FIRST LESION)" 17003_3 CDM 360 RC 17003 HCPCS outpatient 14 10.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 11.91 85.07 999999999 10.92 13.3 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES); SECOND THROUGH 14 LESIONS, EACH (LIST SEPARATELY IN ADDITION TO CODE FOR FIRST LESION)" 17003_3 CDM 360 RC 17003 HCPCS outpatient 14 10.5 MOLINA MCAID MOLINA MCAID 11.68 83.4 999999999 10.92 13.3 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES); SECOND THROUGH 14 LESIONS, EACH (LIST SEPARATELY IN ADDITION TO CODE FOR FIRST LESION)" 17003_3 CDM 360 RC 17003 HCPCS outpatient 14 10.5 MOLINA MCR ADV MOLINA MCR ADV 12.46 89 999999999 10.92 13.3 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES); SECOND THROUGH 14 LESIONS, EACH (LIST SEPARATELY IN ADDITION TO CODE FOR FIRST LESION)" 17003_3 CDM 360 RC 17003 HCPCS outpatient 14 10.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 12.46 89 999999999 10.92 13.3 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES); SECOND THROUGH 14 LESIONS, EACH (LIST SEPARATELY IN ADDITION TO CODE FOR FIRST LESION)" 17003_3 CDM 360 RC 17003 HCPCS outpatient 14 10.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 12.46 89 999999999 10.92 13.3 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES); SECOND THROUGH 14 LESIONS, EACH (LIST SEPARATELY IN ADDITION TO CODE FOR FIRST LESION)" 17003_3 CDM 360 RC 17003 HCPCS outpatient 14 10.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 12.6 90 999999999 10.92 13.3 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES); SECOND THROUGH 14 LESIONS, EACH (LIST SEPARATELY IN ADDITION TO CODE FOR FIRST LESION)" 17003_3 CDM 360 RC 17003 HCPCS outpatient 14 10.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 13.3 95 999999999 10.92 13.3 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES); SECOND THROUGH 14 LESIONS, EACH (LIST SEPARATELY IN ADDITION TO CODE FOR FIRST LESION)" 17003_3 CDM 360 RC 17003 HCPCS outpatient 14 10.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 13.3 95 999999999 10.92 13.3 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES); SECOND THROUGH 14 LESIONS, EACH (LIST SEPARATELY IN ADDITION TO CODE FOR FIRST LESION)" 17003_3 CDM 360 RC 17003 HCPCS outpatient 14 10.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 12.46 89 999999999 10.92 13.3 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES); SECOND THROUGH 14 LESIONS, EACH (LIST SEPARATELY IN ADDITION TO CODE FOR FIRST LESION)" 17003_3 CDM 360 RC 17003 HCPCS outpatient 14 10.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 12.32 88 999999999 10.92 13.3 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES); SECOND THROUGH 14 LESIONS, EACH (LIST SEPARATELY IN ADDITION TO CODE FOR FIRST LESION)" 17003_3 CDM 360 RC 17003 HCPCS outpatient 14 10.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 12.46 89 999999999 10.92 13.3 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES), 15 OR MORE LESIONS" 17004_3 CDM 360 RC 17004 HCPCS outpatient 347 260.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 312.3 999999999 270.66 329.65 case rate "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES), 15 OR MORE LESIONS" 17004_3 CDM 360 RC 17004 HCPCS outpatient 347 260.25 AETNA MCR ADV AETNA MCR ADV 270.66 78 999999999 270.66 329.65 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES), 15 OR MORE LESIONS" 17004_3 CDM 360 RC 17004 HCPCS outpatient 347 260.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 303.87 87.57 999999999 270.66 329.65 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES), 15 OR MORE LESIONS" 17004_3 CDM 360 RC 17004 HCPCS outpatient 347 260.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 295.19 85.07 999999999 270.66 329.65 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES), 15 OR MORE LESIONS" 17004_3 CDM 360 RC 17004 HCPCS outpatient 347 260.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 295.19 85.07 999999999 270.66 329.65 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES), 15 OR MORE LESIONS" 17004_3 CDM 360 RC 17004 HCPCS outpatient 347 260.25 MOLINA MCAID MOLINA MCAID 289.4 83.4 999999999 270.66 329.65 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES), 15 OR MORE LESIONS" 17004_3 CDM 360 RC 17004 HCPCS outpatient 347 260.25 MOLINA MCR ADV MOLINA MCR ADV 308.83 89 999999999 270.66 329.65 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES), 15 OR MORE LESIONS" 17004_3 CDM 360 RC 17004 HCPCS outpatient 347 260.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 308.83 89 999999999 270.66 329.65 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES), 15 OR MORE LESIONS" 17004_3 CDM 360 RC 17004 HCPCS outpatient 347 260.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 308.83 89 999999999 270.66 329.65 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES), 15 OR MORE LESIONS" 17004_3 CDM 360 RC 17004 HCPCS outpatient 347 260.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 312.3 90 999999999 270.66 329.65 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES), 15 OR MORE LESIONS" 17004_3 CDM 360 RC 17004 HCPCS outpatient 347 260.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 329.65 95 999999999 270.66 329.65 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES), 15 OR MORE LESIONS" 17004_3 CDM 360 RC 17004 HCPCS outpatient 347 260.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 329.65 95 999999999 270.66 329.65 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES), 15 OR MORE LESIONS" 17004_3 CDM 360 RC 17004 HCPCS outpatient 347 260.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 308.83 89 999999999 270.66 329.65 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES), 15 OR MORE LESIONS" 17004_3 CDM 360 RC 17004 HCPCS outpatient 347 260.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 305.36 88 999999999 270.66 329.65 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES), 15 OR MORE LESIONS" 17004_3 CDM 360 RC 17004 HCPCS outpatient 347 260.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 308.83 89 999999999 270.66 329.65 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; UP TO 14 LESIONS" 17110_3 CDM 360 RC 17110 HCPCS outpatient 234 175.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 210.6 999999999 182.52 222.3 case rate "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; UP TO 14 LESIONS" 17110_3 CDM 360 RC 17110 HCPCS outpatient 234 175.5 AETNA MCR ADV AETNA MCR ADV 182.52 78 999999999 182.52 222.3 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; UP TO 14 LESIONS" 17110_3 CDM 360 RC 17110 HCPCS outpatient 234 175.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 204.91 87.57 999999999 182.52 222.3 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; UP TO 14 LESIONS" 17110_3 CDM 360 RC 17110 HCPCS outpatient 234 175.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 199.06 85.07 999999999 182.52 222.3 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; UP TO 14 LESIONS" 17110_3 CDM 360 RC 17110 HCPCS outpatient 234 175.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 199.06 85.07 999999999 182.52 222.3 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; UP TO 14 LESIONS" 17110_3 CDM 360 RC 17110 HCPCS outpatient 234 175.5 MOLINA MCAID MOLINA MCAID 195.16 83.4 999999999 182.52 222.3 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; UP TO 14 LESIONS" 17110_3 CDM 360 RC 17110 HCPCS outpatient 234 175.5 MOLINA MCR ADV MOLINA MCR ADV 208.26 89 999999999 182.52 222.3 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; UP TO 14 LESIONS" 17110_3 CDM 360 RC 17110 HCPCS outpatient 234 175.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 208.26 89 999999999 182.52 222.3 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; UP TO 14 LESIONS" 17110_3 CDM 360 RC 17110 HCPCS outpatient 234 175.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 208.26 89 999999999 182.52 222.3 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; UP TO 14 LESIONS" 17110_3 CDM 360 RC 17110 HCPCS outpatient 234 175.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 210.6 90 999999999 182.52 222.3 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; UP TO 14 LESIONS" 17110_3 CDM 360 RC 17110 HCPCS outpatient 234 175.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 222.3 95 999999999 182.52 222.3 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; UP TO 14 LESIONS" 17110_3 CDM 360 RC 17110 HCPCS outpatient 234 175.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 222.3 95 999999999 182.52 222.3 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; UP TO 14 LESIONS" 17110_3 CDM 360 RC 17110 HCPCS outpatient 234 175.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 208.26 89 999999999 182.52 222.3 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; UP TO 14 LESIONS" 17110_3 CDM 360 RC 17110 HCPCS outpatient 234 175.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 205.92 88 999999999 182.52 222.3 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; UP TO 14 LESIONS" 17110_3 CDM 360 RC 17110 HCPCS outpatient 234 175.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 208.26 89 999999999 182.52 222.3 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; 15 OR MORE LESIONS" 17111_3 CDM 360 RC 17111 HCPCS outpatient 274 205.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 246.6 999999999 213.72 260.3 case rate "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; 15 OR MORE LESIONS" 17111_3 CDM 360 RC 17111 HCPCS outpatient 274 205.5 AETNA MCR ADV AETNA MCR ADV 213.72 78 999999999 213.72 260.3 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; 15 OR MORE LESIONS" 17111_3 CDM 360 RC 17111 HCPCS outpatient 274 205.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 239.94 87.57 999999999 213.72 260.3 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; 15 OR MORE LESIONS" 17111_3 CDM 360 RC 17111 HCPCS outpatient 274 205.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 233.09 85.07 999999999 213.72 260.3 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; 15 OR MORE LESIONS" 17111_3 CDM 360 RC 17111 HCPCS outpatient 274 205.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 233.09 85.07 999999999 213.72 260.3 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; 15 OR MORE LESIONS" 17111_3 CDM 360 RC 17111 HCPCS outpatient 274 205.5 MOLINA MCAID MOLINA MCAID 228.52 83.4 999999999 213.72 260.3 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; 15 OR MORE LESIONS" 17111_3 CDM 360 RC 17111 HCPCS outpatient 274 205.5 MOLINA MCR ADV MOLINA MCR ADV 243.86 89 999999999 213.72 260.3 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; 15 OR MORE LESIONS" 17111_3 CDM 360 RC 17111 HCPCS outpatient 274 205.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 243.86 89 999999999 213.72 260.3 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; 15 OR MORE LESIONS" 17111_3 CDM 360 RC 17111 HCPCS outpatient 274 205.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 243.86 89 999999999 213.72 260.3 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; 15 OR MORE LESIONS" 17111_3 CDM 360 RC 17111 HCPCS outpatient 274 205.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 246.6 90 999999999 213.72 260.3 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; 15 OR MORE LESIONS" 17111_3 CDM 360 RC 17111 HCPCS outpatient 274 205.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 260.3 95 999999999 213.72 260.3 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; 15 OR MORE LESIONS" 17111_3 CDM 360 RC 17111 HCPCS outpatient 274 205.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 260.3 95 999999999 213.72 260.3 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; 15 OR MORE LESIONS" 17111_3 CDM 360 RC 17111 HCPCS outpatient 274 205.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 243.86 89 999999999 213.72 260.3 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; 15 OR MORE LESIONS" 17111_3 CDM 360 RC 17111 HCPCS outpatient 274 205.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 241.12 88 999999999 213.72 260.3 percent of total billed charges "DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; 15 OR MORE LESIONS" 17111_3 CDM 360 RC 17111 HCPCS outpatient 274 205.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 243.86 89 999999999 213.72 260.3 percent of total billed charges LEAVE OF ABSENCE - GENERAL CLASSIFICATION 1800000001_1 CDM 180 RC inpatient 300 225 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 270 90 999999999 264 10619 percent of total billed charges LEAVE OF ABSENCE - GENERAL CLASSIFICATION 1800000001_1 CDM 180 RC inpatient 300 225 AETNA MCR ADV AETNA MCR ADV 10619 999999999 264 10619 per diem LEAVE OF ABSENCE - GENERAL CLASSIFICATION 1800000001_1 CDM 180 RC inpatient 300 225 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 559.62 186.54 999999999 264 10619 percent of total billed charges LEAVE OF ABSENCE - GENERAL CLASSIFICATION 1800000001_1 CDM 180 RC inpatient 300 225 COORDINATED CARE MCAID COORDINATED CARE MCAID 543.63 181.21 999999999 264 10619 percent of total billed charges LEAVE OF ABSENCE - GENERAL CLASSIFICATION 1800000001_1 CDM 180 RC inpatient 300 225 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 543.63 181.21 999999999 264 10619 percent of total billed charges LEAVE OF ABSENCE - GENERAL CLASSIFICATION 1800000001_1 CDM 180 RC inpatient 300 225 MOLINA MCAID MOLINA MCAID 532.98 177.66 999999999 264 10619 percent of total billed charges LEAVE OF ABSENCE - GENERAL CLASSIFICATION 1800000001_1 CDM 180 RC inpatient 300 225 MOLINA MCR ADV MOLINA MCR ADV 8243 999999999 264 10619 per diem LEAVE OF ABSENCE - GENERAL CLASSIFICATION 1800000001_1 CDM 180 RC inpatient 300 225 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 8243 999999999 264 10619 per diem LEAVE OF ABSENCE - GENERAL CLASSIFICATION 1800000001_1 CDM 180 RC inpatient 300 225 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 8243 999999999 264 10619 per diem LEAVE OF ABSENCE - GENERAL CLASSIFICATION 1800000001_1 CDM 180 RC inpatient 300 225 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 270 90 999999999 264 10619 percent of total billed charges LEAVE OF ABSENCE - GENERAL CLASSIFICATION 1800000001_1 CDM 180 RC inpatient 300 225 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 285 95 999999999 264 10619 percent of total billed charges LEAVE OF ABSENCE - GENERAL CLASSIFICATION 1800000001_1 CDM 180 RC inpatient 300 225 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 285 95 999999999 264 10619 percent of total billed charges LEAVE OF ABSENCE - GENERAL CLASSIFICATION 1800000001_1 CDM 180 RC inpatient 300 225 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 8243 999999999 264 10619 per diem LEAVE OF ABSENCE - GENERAL CLASSIFICATION 1800000001_1 CDM 180 RC inpatient 300 225 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 264 88 999999999 264 10619 percent of total billed charges LEAVE OF ABSENCE - GENERAL CLASSIFICATION 1800000001_1 CDM 180 RC inpatient 300 225 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 7006.55 999999999 264 10619 per diem LEAVE OF ABSENCE - GENERAL CLASSIFICATION 1800000002_1 CDM 180 RC inpatient 1282 961.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1153.8 90 999999999 1128.16 10619 percent of total billed charges LEAVE OF ABSENCE - GENERAL CLASSIFICATION 1800000002_1 CDM 180 RC inpatient 1282 961.5 AETNA MCR ADV AETNA MCR ADV 10619 999999999 1128.16 10619 per diem LEAVE OF ABSENCE - GENERAL CLASSIFICATION 1800000002_1 CDM 180 RC inpatient 1282 961.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 2391.44 186.54 999999999 1128.16 10619 percent of total billed charges LEAVE OF ABSENCE - GENERAL CLASSIFICATION 1800000002_1 CDM 180 RC inpatient 1282 961.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 2323.11 181.21 999999999 1128.16 10619 percent of total billed charges LEAVE OF ABSENCE - GENERAL CLASSIFICATION 1800000002_1 CDM 180 RC inpatient 1282 961.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 2323.11 181.21 999999999 1128.16 10619 percent of total billed charges LEAVE OF ABSENCE - GENERAL CLASSIFICATION 1800000002_1 CDM 180 RC inpatient 1282 961.5 MOLINA MCAID MOLINA MCAID 2277.6 177.66 999999999 1128.16 10619 percent of total billed charges LEAVE OF ABSENCE - GENERAL CLASSIFICATION 1800000002_1 CDM 180 RC inpatient 1282 961.5 MOLINA MCR ADV MOLINA MCR ADV 8243 999999999 1128.16 10619 per diem LEAVE OF ABSENCE - GENERAL CLASSIFICATION 1800000002_1 CDM 180 RC inpatient 1282 961.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 8243 999999999 1128.16 10619 per diem LEAVE OF ABSENCE - GENERAL CLASSIFICATION 1800000002_1 CDM 180 RC inpatient 1282 961.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 8243 999999999 1128.16 10619 per diem LEAVE OF ABSENCE - GENERAL CLASSIFICATION 1800000002_1 CDM 180 RC inpatient 1282 961.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1153.8 90 999999999 1128.16 10619 percent of total billed charges LEAVE OF ABSENCE - GENERAL CLASSIFICATION 1800000002_1 CDM 180 RC inpatient 1282 961.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1217.9 95 999999999 1128.16 10619 percent of total billed charges LEAVE OF ABSENCE - GENERAL CLASSIFICATION 1800000002_1 CDM 180 RC inpatient 1282 961.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1217.9 95 999999999 1128.16 10619 percent of total billed charges LEAVE OF ABSENCE - GENERAL CLASSIFICATION 1800000002_1 CDM 180 RC inpatient 1282 961.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 8243 999999999 1128.16 10619 per diem LEAVE OF ABSENCE - GENERAL CLASSIFICATION 1800000002_1 CDM 180 RC inpatient 1282 961.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1128.16 88 999999999 1128.16 10619 percent of total billed charges LEAVE OF ABSENCE - GENERAL CLASSIFICATION 1800000002_1 CDM 180 RC inpatient 1282 961.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 7006.55 999999999 1128.16 10619 per diem SUBACUTE CARE - GENERAL CLASSIFICATION 1900000001_1 CDM 190 RC inpatient 1282 961.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1153.8 90 999999999 1128.16 10159 percent of total billed charges SUBACUTE CARE - GENERAL CLASSIFICATION 1900000001_1 CDM 190 RC inpatient 1282 961.5 AETNA MCR ADV AETNA MCR ADV 10159 999999999 1128.16 10159 per diem SUBACUTE CARE - GENERAL CLASSIFICATION 1900000001_1 CDM 190 RC inpatient 1282 961.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 2391.44 186.54 999999999 1128.16 10159 percent of total billed charges SUBACUTE CARE - GENERAL CLASSIFICATION 1900000001_1 CDM 190 RC inpatient 1282 961.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 2323.11 181.21 999999999 1128.16 10159 percent of total billed charges SUBACUTE CARE - GENERAL CLASSIFICATION 1900000001_1 CDM 190 RC inpatient 1282 961.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 2323.11 181.21 999999999 1128.16 10159 percent of total billed charges SUBACUTE CARE - GENERAL CLASSIFICATION 1900000001_1 CDM 190 RC inpatient 1282 961.5 MOLINA MCAID MOLINA MCAID 2277.6 177.66 999999999 1128.16 10159 percent of total billed charges SUBACUTE CARE - GENERAL CLASSIFICATION 1900000001_1 CDM 190 RC inpatient 1282 961.5 MOLINA MCR ADV MOLINA MCR ADV 8243 999999999 1128.16 10159 per diem SUBACUTE CARE - GENERAL CLASSIFICATION 1900000001_1 CDM 190 RC inpatient 1282 961.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 8243 999999999 1128.16 10159 per diem SUBACUTE CARE - GENERAL CLASSIFICATION 1900000001_1 CDM 190 RC inpatient 1282 961.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 8243 999999999 1128.16 10159 per diem SUBACUTE CARE - GENERAL CLASSIFICATION 1900000001_1 CDM 190 RC inpatient 1282 961.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1153.8 90 999999999 1128.16 10159 percent of total billed charges SUBACUTE CARE - GENERAL CLASSIFICATION 1900000001_1 CDM 190 RC inpatient 1282 961.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1217.9 95 999999999 1128.16 10159 percent of total billed charges SUBACUTE CARE - GENERAL CLASSIFICATION 1900000001_1 CDM 190 RC inpatient 1282 961.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1217.9 95 999999999 1128.16 10159 percent of total billed charges SUBACUTE CARE - GENERAL CLASSIFICATION 1900000001_1 CDM 190 RC inpatient 1282 961.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 8243 999999999 1128.16 10159 per diem SUBACUTE CARE - GENERAL CLASSIFICATION 1900000001_1 CDM 190 RC inpatient 1282 961.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1128.16 88 999999999 1128.16 10159 percent of total billed charges SUBACUTE CARE - GENERAL CLASSIFICATION 1900000001_1 CDM 190 RC inpatient 1282 961.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 7006.55 999999999 1128.16 10159 per diem REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH; DEEP OR COMPLICATED 20525_3 CDM 360 RC 20525 HCPCS outpatient 968 726 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 871.2 999999999 755.04 919.6 case rate REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH; DEEP OR COMPLICATED 20525_3 CDM 360 RC 20525 HCPCS outpatient 968 726 AETNA MCR ADV AETNA MCR ADV 755.04 78 999999999 755.04 919.6 percent of total billed charges REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH; DEEP OR COMPLICATED 20525_3 CDM 360 RC 20525 HCPCS outpatient 968 726 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 847.68 87.57 999999999 755.04 919.6 percent of total billed charges REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH; DEEP OR COMPLICATED 20525_3 CDM 360 RC 20525 HCPCS outpatient 968 726 COORDINATED CARE MCAID COORDINATED CARE MCAID 823.48 85.07 999999999 755.04 919.6 percent of total billed charges REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH; DEEP OR COMPLICATED 20525_3 CDM 360 RC 20525 HCPCS outpatient 968 726 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 823.48 85.07 999999999 755.04 919.6 percent of total billed charges REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH; DEEP OR COMPLICATED 20525_3 CDM 360 RC 20525 HCPCS outpatient 968 726 MOLINA MCAID MOLINA MCAID 807.31 83.4 999999999 755.04 919.6 percent of total billed charges REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH; DEEP OR COMPLICATED 20525_3 CDM 360 RC 20525 HCPCS outpatient 968 726 MOLINA MCR ADV MOLINA MCR ADV 861.52 89 999999999 755.04 919.6 percent of total billed charges REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH; DEEP OR COMPLICATED 20525_3 CDM 360 RC 20525 HCPCS outpatient 968 726 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 861.52 89 999999999 755.04 919.6 percent of total billed charges REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH; DEEP OR COMPLICATED 20525_3 CDM 360 RC 20525 HCPCS outpatient 968 726 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 861.52 89 999999999 755.04 919.6 percent of total billed charges REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH; DEEP OR COMPLICATED 20525_3 CDM 360 RC 20525 HCPCS outpatient 968 726 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 871.2 90 999999999 755.04 919.6 percent of total billed charges REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH; DEEP OR COMPLICATED 20525_3 CDM 360 RC 20525 HCPCS outpatient 968 726 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 919.6 95 999999999 755.04 919.6 percent of total billed charges REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH; DEEP OR COMPLICATED 20525_3 CDM 360 RC 20525 HCPCS outpatient 968 726 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 919.6 95 999999999 755.04 919.6 percent of total billed charges REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH; DEEP OR COMPLICATED 20525_3 CDM 360 RC 20525 HCPCS outpatient 968 726 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 861.52 89 999999999 755.04 919.6 percent of total billed charges REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH; DEEP OR COMPLICATED 20525_3 CDM 360 RC 20525 HCPCS outpatient 968 726 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 851.84 88 999999999 755.04 919.6 percent of total billed charges REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH; DEEP OR COMPLICATED 20525_3 CDM 360 RC 20525 HCPCS outpatient 968 726 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 861.52 89 999999999 755.04 919.6 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_1 CDM 360 RC 20550 HCPCS outpatient 435 326.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 391.5 999999999 339.3 413.25 case rate "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_1 CDM 360 RC 20550 HCPCS outpatient 435 326.25 AETNA MCR ADV AETNA MCR ADV 339.3 78 999999999 339.3 413.25 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_1 CDM 360 RC 20550 HCPCS outpatient 435 326.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 380.93 87.57 999999999 339.3 413.25 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_1 CDM 360 RC 20550 HCPCS outpatient 435 326.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 370.05 85.07 999999999 339.3 413.25 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_1 CDM 360 RC 20550 HCPCS outpatient 435 326.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 370.05 85.07 999999999 339.3 413.25 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_1 CDM 360 RC 20550 HCPCS outpatient 435 326.25 MOLINA MCAID MOLINA MCAID 362.79 83.4 999999999 339.3 413.25 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_1 CDM 360 RC 20550 HCPCS outpatient 435 326.25 MOLINA MCR ADV MOLINA MCR ADV 387.15 89 999999999 339.3 413.25 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_1 CDM 360 RC 20550 HCPCS outpatient 435 326.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 387.15 89 999999999 339.3 413.25 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_1 CDM 360 RC 20550 HCPCS outpatient 435 326.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 387.15 89 999999999 339.3 413.25 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_1 CDM 360 RC 20550 HCPCS outpatient 435 326.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 391.5 90 999999999 339.3 413.25 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_1 CDM 360 RC 20550 HCPCS outpatient 435 326.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 413.25 95 999999999 339.3 413.25 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_1 CDM 360 RC 20550 HCPCS outpatient 435 326.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 413.25 95 999999999 339.3 413.25 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_1 CDM 360 RC 20550 HCPCS outpatient 435 326.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 387.15 89 999999999 339.3 413.25 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_1 CDM 360 RC 20550 HCPCS outpatient 435 326.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 382.8 88 999999999 339.3 413.25 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_1 CDM 360 RC 20550 HCPCS outpatient 435 326.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 387.15 89 999999999 339.3 413.25 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_3 CDM 360 RC 20550 HCPCS outpatient 117 87.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 105.3 999999999 91.26 111.15 case rate "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_3 CDM 360 RC 20550 HCPCS outpatient 117 87.75 AETNA MCR ADV AETNA MCR ADV 91.26 78 999999999 91.26 111.15 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_3 CDM 360 RC 20550 HCPCS outpatient 117 87.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 102.46 87.57 999999999 91.26 111.15 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_3 CDM 360 RC 20550 HCPCS outpatient 117 87.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 99.53 85.07 999999999 91.26 111.15 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_3 CDM 360 RC 20550 HCPCS outpatient 117 87.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 99.53 85.07 999999999 91.26 111.15 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_3 CDM 360 RC 20550 HCPCS outpatient 117 87.75 MOLINA MCAID MOLINA MCAID 97.58 83.4 999999999 91.26 111.15 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_3 CDM 360 RC 20550 HCPCS outpatient 117 87.75 MOLINA MCR ADV MOLINA MCR ADV 104.13 89 999999999 91.26 111.15 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_3 CDM 360 RC 20550 HCPCS outpatient 117 87.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 104.13 89 999999999 91.26 111.15 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_3 CDM 360 RC 20550 HCPCS outpatient 117 87.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 104.13 89 999999999 91.26 111.15 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_3 CDM 360 RC 20550 HCPCS outpatient 117 87.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 105.3 90 999999999 91.26 111.15 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_3 CDM 360 RC 20550 HCPCS outpatient 117 87.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 111.15 95 999999999 91.26 111.15 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_3 CDM 360 RC 20550 HCPCS outpatient 117 87.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 111.15 95 999999999 91.26 111.15 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_3 CDM 360 RC 20550 HCPCS outpatient 117 87.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 104.13 89 999999999 91.26 111.15 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_3 CDM 360 RC 20550 HCPCS outpatient 117 87.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 102.96 88 999999999 91.26 111.15 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_3 CDM 360 RC 20550 HCPCS outpatient 117 87.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 104.13 89 999999999 91.26 111.15 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_50_1 CDM 360 RC 20550 HCPCS outpatient 650 487.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 585 999999999 507 617.5 case rate "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_50_1 CDM 360 RC 20550 HCPCS outpatient 650 487.5 AETNA MCR ADV AETNA MCR ADV 50 507 78 999999999 507 617.5 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_50_1 CDM 360 RC 20550 HCPCS outpatient 650 487.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 569.21 87.57 999999999 507 617.5 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_50_1 CDM 360 RC 20550 HCPCS outpatient 650 487.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 552.96 85.07 999999999 507 617.5 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_50_1 CDM 360 RC 20550 HCPCS outpatient 650 487.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 552.96 85.07 999999999 507 617.5 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_50_1 CDM 360 RC 20550 HCPCS outpatient 650 487.5 MOLINA MCAID MOLINA MCAID 50 542.1 83.4 999999999 507 617.5 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_50_1 CDM 360 RC 20550 HCPCS outpatient 650 487.5 MOLINA MCR ADV MOLINA MCR ADV 50 578.5 89 999999999 507 617.5 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_50_1 CDM 360 RC 20550 HCPCS outpatient 650 487.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 578.5 89 999999999 507 617.5 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_50_1 CDM 360 RC 20550 HCPCS outpatient 650 487.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 578.5 89 999999999 507 617.5 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_50_1 CDM 360 RC 20550 HCPCS outpatient 650 487.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 585 90 999999999 507 617.5 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_50_1 CDM 360 RC 20550 HCPCS outpatient 650 487.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 617.5 95 999999999 507 617.5 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_50_1 CDM 360 RC 20550 HCPCS outpatient 650 487.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 617.5 95 999999999 507 617.5 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_50_1 CDM 360 RC 20550 HCPCS outpatient 650 487.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 578.5 89 999999999 507 617.5 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_50_1 CDM 360 RC 20550 HCPCS outpatient 650 487.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 572 88 999999999 507 617.5 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 20550_50_1 CDM 360 RC 20550 HCPCS outpatient 650 487.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 578.5 89 999999999 507 617.5 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_1 CDM 490 RC 20552 HCPCS outpatient 421 315.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 378.9 999999999 328.38 399.95 case rate "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_1 CDM 490 RC 20552 HCPCS outpatient 421 315.75 AETNA MCR ADV AETNA MCR ADV 328.38 78 999999999 328.38 399.95 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_1 CDM 490 RC 20552 HCPCS outpatient 421 315.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 368.67 87.57 999999999 328.38 399.95 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_1 CDM 490 RC 20552 HCPCS outpatient 421 315.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 358.14 85.07 999999999 328.38 399.95 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_1 CDM 490 RC 20552 HCPCS outpatient 421 315.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 358.14 85.07 999999999 328.38 399.95 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_1 CDM 490 RC 20552 HCPCS outpatient 421 315.75 MOLINA MCAID MOLINA MCAID 351.11 83.4 999999999 328.38 399.95 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_1 CDM 490 RC 20552 HCPCS outpatient 421 315.75 MOLINA MCR ADV MOLINA MCR ADV 374.69 89 999999999 328.38 399.95 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_1 CDM 490 RC 20552 HCPCS outpatient 421 315.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 374.69 89 999999999 328.38 399.95 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_1 CDM 490 RC 20552 HCPCS outpatient 421 315.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 374.69 89 999999999 328.38 399.95 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_1 CDM 490 RC 20552 HCPCS outpatient 421 315.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 378.9 90 999999999 328.38 399.95 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_1 CDM 490 RC 20552 HCPCS outpatient 421 315.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 399.95 95 999999999 328.38 399.95 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_1 CDM 490 RC 20552 HCPCS outpatient 421 315.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 399.95 95 999999999 328.38 399.95 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_1 CDM 490 RC 20552 HCPCS outpatient 421 315.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 374.69 89 999999999 328.38 399.95 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_1 CDM 490 RC 20552 HCPCS outpatient 421 315.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 370.48 88 999999999 328.38 399.95 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_1 CDM 490 RC 20552 HCPCS outpatient 421 315.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 374.69 89 999999999 328.38 399.95 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_3 CDM 490 RC 20552 HCPCS outpatient 109 81.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 98.1 999999999 85.02 103.55 case rate "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_3 CDM 490 RC 20552 HCPCS outpatient 109 81.75 AETNA MCR ADV AETNA MCR ADV 85.02 78 999999999 85.02 103.55 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_3 CDM 490 RC 20552 HCPCS outpatient 109 81.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 95.45 87.57 999999999 85.02 103.55 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_3 CDM 490 RC 20552 HCPCS outpatient 109 81.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 92.73 85.07 999999999 85.02 103.55 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_3 CDM 490 RC 20552 HCPCS outpatient 109 81.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 92.73 85.07 999999999 85.02 103.55 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_3 CDM 490 RC 20552 HCPCS outpatient 109 81.75 MOLINA MCAID MOLINA MCAID 90.91 83.4 999999999 85.02 103.55 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_3 CDM 490 RC 20552 HCPCS outpatient 109 81.75 MOLINA MCR ADV MOLINA MCR ADV 97.01 89 999999999 85.02 103.55 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_3 CDM 490 RC 20552 HCPCS outpatient 109 81.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 97.01 89 999999999 85.02 103.55 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_3 CDM 490 RC 20552 HCPCS outpatient 109 81.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 97.01 89 999999999 85.02 103.55 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_3 CDM 490 RC 20552 HCPCS outpatient 109 81.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 98.1 90 999999999 85.02 103.55 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_3 CDM 490 RC 20552 HCPCS outpatient 109 81.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 103.55 95 999999999 85.02 103.55 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_3 CDM 490 RC 20552 HCPCS outpatient 109 81.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 103.55 95 999999999 85.02 103.55 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_3 CDM 490 RC 20552 HCPCS outpatient 109 81.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 97.01 89 999999999 85.02 103.55 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_3 CDM 490 RC 20552 HCPCS outpatient 109 81.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 95.92 88 999999999 85.02 103.55 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_3 CDM 490 RC 20552 HCPCS outpatient 109 81.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 97.01 89 999999999 85.02 103.55 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_50_1 CDM 490 RC 20552 HCPCS outpatient 632 474 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 568.8 999999999 492.96 600.4 case rate "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_50_1 CDM 490 RC 20552 HCPCS outpatient 632 474 AETNA MCR ADV AETNA MCR ADV 50 492.96 78 999999999 492.96 600.4 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_50_1 CDM 490 RC 20552 HCPCS outpatient 632 474 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 553.44 87.57 999999999 492.96 600.4 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_50_1 CDM 490 RC 20552 HCPCS outpatient 632 474 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 537.64 85.07 999999999 492.96 600.4 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_50_1 CDM 490 RC 20552 HCPCS outpatient 632 474 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 537.64 85.07 999999999 492.96 600.4 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_50_1 CDM 490 RC 20552 HCPCS outpatient 632 474 MOLINA MCAID MOLINA MCAID 50 527.09 83.4 999999999 492.96 600.4 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_50_1 CDM 490 RC 20552 HCPCS outpatient 632 474 MOLINA MCR ADV MOLINA MCR ADV 50 562.48 89 999999999 492.96 600.4 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_50_1 CDM 490 RC 20552 HCPCS outpatient 632 474 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 562.48 89 999999999 492.96 600.4 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_50_1 CDM 490 RC 20552 HCPCS outpatient 632 474 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 562.48 89 999999999 492.96 600.4 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_50_1 CDM 490 RC 20552 HCPCS outpatient 632 474 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 568.8 90 999999999 492.96 600.4 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_50_1 CDM 490 RC 20552 HCPCS outpatient 632 474 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 600.4 95 999999999 492.96 600.4 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_50_1 CDM 490 RC 20552 HCPCS outpatient 632 474 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 600.4 95 999999999 492.96 600.4 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_50_1 CDM 490 RC 20552 HCPCS outpatient 632 474 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 562.48 89 999999999 492.96 600.4 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_50_1 CDM 490 RC 20552 HCPCS outpatient 632 474 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 556.16 88 999999999 492.96 600.4 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 20552_50_1 CDM 490 RC 20552 HCPCS outpatient 632 474 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 562.48 89 999999999 492.96 600.4 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 20553_1 CDM 490 RC 20553 HCPCS outpatient 535 401.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 481.5 999999999 417.3 508.25 case rate "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 20553_1 CDM 490 RC 20553 HCPCS outpatient 535 401.25 AETNA MCR ADV AETNA MCR ADV 417.3 78 999999999 417.3 508.25 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 20553_1 CDM 490 RC 20553 HCPCS outpatient 535 401.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 468.5 87.57 999999999 417.3 508.25 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 20553_1 CDM 490 RC 20553 HCPCS outpatient 535 401.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 455.12 85.07 999999999 417.3 508.25 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 20553_1 CDM 490 RC 20553 HCPCS outpatient 535 401.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 455.12 85.07 999999999 417.3 508.25 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 20553_1 CDM 490 RC 20553 HCPCS outpatient 535 401.25 MOLINA MCAID MOLINA MCAID 446.19 83.4 999999999 417.3 508.25 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 20553_1 CDM 490 RC 20553 HCPCS outpatient 535 401.25 MOLINA MCR ADV MOLINA MCR ADV 476.15 89 999999999 417.3 508.25 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 20553_1 CDM 490 RC 20553 HCPCS outpatient 535 401.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 476.15 89 999999999 417.3 508.25 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 20553_1 CDM 490 RC 20553 HCPCS outpatient 535 401.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 476.15 89 999999999 417.3 508.25 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 20553_1 CDM 490 RC 20553 HCPCS outpatient 535 401.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 481.5 90 999999999 417.3 508.25 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 20553_1 CDM 490 RC 20553 HCPCS outpatient 535 401.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 508.25 95 999999999 417.3 508.25 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 20553_1 CDM 490 RC 20553 HCPCS outpatient 535 401.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 508.25 95 999999999 417.3 508.25 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 20553_1 CDM 490 RC 20553 HCPCS outpatient 535 401.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 476.15 89 999999999 417.3 508.25 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 20553_1 CDM 490 RC 20553 HCPCS outpatient 535 401.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 470.8 88 999999999 417.3 508.25 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 20553_1 CDM 490 RC 20553 HCPCS outpatient 535 401.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 476.15 89 999999999 417.3 508.25 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 20553_3 CDM 490 RC 20553 HCPCS outpatient 125 93.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 118.75 95 999999999 97.5 118.75 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 20553_3 CDM 490 RC 20553 HCPCS outpatient 125 93.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 111.25 89 999999999 97.5 118.75 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 20553_3 CDM 490 RC 20553 HCPCS outpatient 125 93.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 110 88 999999999 97.5 118.75 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 20553_3 CDM 490 RC 20553 HCPCS outpatient 125 93.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 111.25 89 999999999 97.5 118.75 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 20553_3 CDM 490 RC 20553 HCPCS outpatient 125 93.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 112.5 999999999 97.5 118.75 case rate "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 20553_3 CDM 490 RC 20553 HCPCS outpatient 125 93.75 AETNA MCR ADV AETNA MCR ADV 97.5 78 999999999 97.5 118.75 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 20553_3 CDM 490 RC 20553 HCPCS outpatient 125 93.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 109.46 87.57 999999999 97.5 118.75 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 20553_3 CDM 490 RC 20553 HCPCS outpatient 125 93.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 106.34 85.07 999999999 97.5 118.75 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 20553_3 CDM 490 RC 20553 HCPCS outpatient 125 93.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 106.34 85.07 999999999 97.5 118.75 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 20553_3 CDM 490 RC 20553 HCPCS outpatient 125 93.75 MOLINA MCAID MOLINA MCAID 104.25 83.4 999999999 97.5 118.75 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 20553_3 CDM 490 RC 20553 HCPCS outpatient 125 93.75 MOLINA MCR ADV MOLINA MCR ADV 111.25 89 999999999 97.5 118.75 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 20553_3 CDM 490 RC 20553 HCPCS outpatient 125 93.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 111.25 89 999999999 97.5 118.75 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 20553_3 CDM 490 RC 20553 HCPCS outpatient 125 93.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 111.25 89 999999999 97.5 118.75 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 20553_3 CDM 490 RC 20553 HCPCS outpatient 125 93.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 112.5 90 999999999 97.5 118.75 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 20553_3 CDM 490 RC 20553 HCPCS outpatient 125 93.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 118.75 95 999999999 97.5 118.75 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, SMALL JOINT OR BURSA (EG, FINGERS, TOES); WITHOUT ULTRASOUND GUIDANCE" 20600_3 CDM 360 RC 20600 HCPCS outpatient 108 81 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 97.2 999999999 84.24 102.6 case rate "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, SMALL JOINT OR BURSA (EG, FINGERS, TOES); WITHOUT ULTRASOUND GUIDANCE" 20600_3 CDM 360 RC 20600 HCPCS outpatient 108 81 AETNA MCR ADV AETNA MCR ADV 84.24 78 999999999 84.24 102.6 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, SMALL JOINT OR BURSA (EG, FINGERS, TOES); WITHOUT ULTRASOUND GUIDANCE" 20600_3 CDM 360 RC 20600 HCPCS outpatient 108 81 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 94.58 87.57 999999999 84.24 102.6 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, SMALL JOINT OR BURSA (EG, FINGERS, TOES); WITHOUT ULTRASOUND GUIDANCE" 20600_3 CDM 360 RC 20600 HCPCS outpatient 108 81 COORDINATED CARE MCAID COORDINATED CARE MCAID 91.88 85.07 999999999 84.24 102.6 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, SMALL JOINT OR BURSA (EG, FINGERS, TOES); WITHOUT ULTRASOUND GUIDANCE" 20600_3 CDM 360 RC 20600 HCPCS outpatient 108 81 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 91.88 85.07 999999999 84.24 102.6 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, SMALL JOINT OR BURSA (EG, FINGERS, TOES); WITHOUT ULTRASOUND GUIDANCE" 20600_3 CDM 360 RC 20600 HCPCS outpatient 108 81 MOLINA MCAID MOLINA MCAID 90.07 83.4 999999999 84.24 102.6 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, SMALL JOINT OR BURSA (EG, FINGERS, TOES); WITHOUT ULTRASOUND GUIDANCE" 20600_3 CDM 360 RC 20600 HCPCS outpatient 108 81 MOLINA MCR ADV MOLINA MCR ADV 96.12 89 999999999 84.24 102.6 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, SMALL JOINT OR BURSA (EG, FINGERS, TOES); WITHOUT ULTRASOUND GUIDANCE" 20600_3 CDM 360 RC 20600 HCPCS outpatient 108 81 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 96.12 89 999999999 84.24 102.6 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, SMALL JOINT OR BURSA (EG, FINGERS, TOES); WITHOUT ULTRASOUND GUIDANCE" 20600_3 CDM 360 RC 20600 HCPCS outpatient 108 81 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 96.12 89 999999999 84.24 102.6 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, SMALL JOINT OR BURSA (EG, FINGERS, TOES); WITHOUT ULTRASOUND GUIDANCE" 20600_3 CDM 360 RC 20600 HCPCS outpatient 108 81 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 97.2 90 999999999 84.24 102.6 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, SMALL JOINT OR BURSA (EG, FINGERS, TOES); WITHOUT ULTRASOUND GUIDANCE" 20600_3 CDM 360 RC 20600 HCPCS outpatient 108 81 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 102.6 95 999999999 84.24 102.6 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, SMALL JOINT OR BURSA (EG, FINGERS, TOES); WITHOUT ULTRASOUND GUIDANCE" 20600_3 CDM 360 RC 20600 HCPCS outpatient 108 81 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 102.6 95 999999999 84.24 102.6 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, SMALL JOINT OR BURSA (EG, FINGERS, TOES); WITHOUT ULTRASOUND GUIDANCE" 20600_3 CDM 360 RC 20600 HCPCS outpatient 108 81 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 96.12 89 999999999 84.24 102.6 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, SMALL JOINT OR BURSA (EG, FINGERS, TOES); WITHOUT ULTRASOUND GUIDANCE" 20600_3 CDM 360 RC 20600 HCPCS outpatient 108 81 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 95.04 88 999999999 84.24 102.6 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, SMALL JOINT OR BURSA (EG, FINGERS, TOES); WITHOUT ULTRASOUND GUIDANCE" 20600_3 CDM 360 RC 20600 HCPCS outpatient 108 81 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 96.12 89 999999999 84.24 102.6 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_1 CDM 490 RC 20605 HCPCS outpatient 111.24 83.43 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 100.12 999999999 86.77 105.68 case rate "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_1 CDM 490 RC 20605 HCPCS outpatient 111.24 83.43 AETNA MCR ADV AETNA MCR ADV 86.77 78 999999999 86.77 105.68 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_1 CDM 490 RC 20605 HCPCS outpatient 111.24 83.43 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 97.41 87.57 999999999 86.77 105.68 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_1 CDM 490 RC 20605 HCPCS outpatient 111.24 83.43 COORDINATED CARE MCAID COORDINATED CARE MCAID 94.63 85.07 999999999 86.77 105.68 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_1 CDM 490 RC 20605 HCPCS outpatient 111.24 83.43 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 94.63 85.07 999999999 86.77 105.68 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_1 CDM 490 RC 20605 HCPCS outpatient 111.24 83.43 MOLINA MCAID MOLINA MCAID 92.77 83.4 999999999 86.77 105.68 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_1 CDM 490 RC 20605 HCPCS outpatient 111.24 83.43 MOLINA MCR ADV MOLINA MCR ADV 99 89 999999999 86.77 105.68 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_1 CDM 490 RC 20605 HCPCS outpatient 111.24 83.43 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 99 89 999999999 86.77 105.68 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_1 CDM 490 RC 20605 HCPCS outpatient 111.24 83.43 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 99 89 999999999 86.77 105.68 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_1 CDM 490 RC 20605 HCPCS outpatient 111.24 83.43 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 100.12 90 999999999 86.77 105.68 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_1 CDM 490 RC 20605 HCPCS outpatient 111.24 83.43 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 105.68 95 999999999 86.77 105.68 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_1 CDM 490 RC 20605 HCPCS outpatient 111.24 83.43 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 105.68 95 999999999 86.77 105.68 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_1 CDM 490 RC 20605 HCPCS outpatient 111.24 83.43 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 99 89 999999999 86.77 105.68 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_1 CDM 490 RC 20605 HCPCS outpatient 111.24 83.43 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 97.89 88 999999999 86.77 105.68 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_1 CDM 490 RC 20605 HCPCS outpatient 111.24 83.43 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 99 89 999999999 86.77 105.68 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_2 CDM 490 RC 20605 HCPCS outpatient 111.24 83.43 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 100.12 999999999 86.77 105.68 case rate "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_2 CDM 490 RC 20605 HCPCS outpatient 111.24 83.43 AETNA MCR ADV AETNA MCR ADV 86.77 78 999999999 86.77 105.68 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_2 CDM 490 RC 20605 HCPCS outpatient 111.24 83.43 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 97.41 87.57 999999999 86.77 105.68 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_2 CDM 490 RC 20605 HCPCS outpatient 111.24 83.43 COORDINATED CARE MCAID COORDINATED CARE MCAID 94.63 85.07 999999999 86.77 105.68 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_2 CDM 490 RC 20605 HCPCS outpatient 111.24 83.43 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 94.63 85.07 999999999 86.77 105.68 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_2 CDM 490 RC 20605 HCPCS outpatient 111.24 83.43 MOLINA MCAID MOLINA MCAID 92.77 83.4 999999999 86.77 105.68 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_2 CDM 490 RC 20605 HCPCS outpatient 111.24 83.43 MOLINA MCR ADV MOLINA MCR ADV 99 89 999999999 86.77 105.68 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_2 CDM 490 RC 20605 HCPCS outpatient 111.24 83.43 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 99 89 999999999 86.77 105.68 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_2 CDM 490 RC 20605 HCPCS outpatient 111.24 83.43 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 99 89 999999999 86.77 105.68 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_2 CDM 490 RC 20605 HCPCS outpatient 111.24 83.43 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 100.12 90 999999999 86.77 105.68 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_2 CDM 490 RC 20605 HCPCS outpatient 111.24 83.43 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 105.68 95 999999999 86.77 105.68 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_2 CDM 490 RC 20605 HCPCS outpatient 111.24 83.43 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 105.68 95 999999999 86.77 105.68 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_2 CDM 490 RC 20605 HCPCS outpatient 111.24 83.43 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 99 89 999999999 86.77 105.68 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_2 CDM 490 RC 20605 HCPCS outpatient 111.24 83.43 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 97.89 88 999999999 86.77 105.68 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_2 CDM 490 RC 20605 HCPCS outpatient 111.24 83.43 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 99 89 999999999 86.77 105.68 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_3 CDM 490 RC 20605 HCPCS outpatient 111 83.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 99.9 999999999 86.58 105.45 case rate "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_3 CDM 490 RC 20605 HCPCS outpatient 111 83.25 AETNA MCR ADV AETNA MCR ADV 86.58 78 999999999 86.58 105.45 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_3 CDM 490 RC 20605 HCPCS outpatient 111 83.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 97.2 87.57 999999999 86.58 105.45 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_3 CDM 490 RC 20605 HCPCS outpatient 111 83.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 94.43 85.07 999999999 86.58 105.45 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_3 CDM 490 RC 20605 HCPCS outpatient 111 83.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 94.43 85.07 999999999 86.58 105.45 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_3 CDM 490 RC 20605 HCPCS outpatient 111 83.25 MOLINA MCAID MOLINA MCAID 92.57 83.4 999999999 86.58 105.45 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_3 CDM 490 RC 20605 HCPCS outpatient 111 83.25 MOLINA MCR ADV MOLINA MCR ADV 98.79 89 999999999 86.58 105.45 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_3 CDM 490 RC 20605 HCPCS outpatient 111 83.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 98.79 89 999999999 86.58 105.45 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_3 CDM 490 RC 20605 HCPCS outpatient 111 83.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 98.79 89 999999999 86.58 105.45 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_3 CDM 490 RC 20605 HCPCS outpatient 111 83.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 99.9 90 999999999 86.58 105.45 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_3 CDM 490 RC 20605 HCPCS outpatient 111 83.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 105.45 95 999999999 86.58 105.45 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_3 CDM 490 RC 20605 HCPCS outpatient 111 83.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 105.45 95 999999999 86.58 105.45 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_3 CDM 490 RC 20605 HCPCS outpatient 111 83.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 98.79 89 999999999 86.58 105.45 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_3 CDM 490 RC 20605 HCPCS outpatient 111 83.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 97.68 88 999999999 86.58 105.45 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 20605_3 CDM 490 RC 20605 HCPCS outpatient 111 83.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 98.79 89 999999999 86.58 105.45 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20606_1 CDM 361 RC 20606 HCPCS outpatient 664 498 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 597.6 999999999 517.92 630.8 case rate "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20606_1 CDM 361 RC 20606 HCPCS outpatient 664 498 AETNA MCR ADV AETNA MCR ADV 517.92 78 999999999 517.92 630.8 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20606_1 CDM 361 RC 20606 HCPCS outpatient 664 498 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 581.46 87.57 999999999 517.92 630.8 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20606_1 CDM 361 RC 20606 HCPCS outpatient 664 498 COORDINATED CARE MCAID COORDINATED CARE MCAID 564.86 85.07 999999999 517.92 630.8 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20606_1 CDM 361 RC 20606 HCPCS outpatient 664 498 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 564.86 85.07 999999999 517.92 630.8 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20606_1 CDM 361 RC 20606 HCPCS outpatient 664 498 MOLINA MCAID MOLINA MCAID 553.78 83.4 999999999 517.92 630.8 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20606_1 CDM 361 RC 20606 HCPCS outpatient 664 498 MOLINA MCR ADV MOLINA MCR ADV 590.96 89 999999999 517.92 630.8 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20606_1 CDM 361 RC 20606 HCPCS outpatient 664 498 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 590.96 89 999999999 517.92 630.8 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20606_1 CDM 361 RC 20606 HCPCS outpatient 664 498 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 590.96 89 999999999 517.92 630.8 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20606_1 CDM 361 RC 20606 HCPCS outpatient 664 498 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 597.6 90 999999999 517.92 630.8 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20606_1 CDM 361 RC 20606 HCPCS outpatient 664 498 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 630.8 95 999999999 517.92 630.8 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20606_1 CDM 361 RC 20606 HCPCS outpatient 664 498 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 630.8 95 999999999 517.92 630.8 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20606_1 CDM 361 RC 20606 HCPCS outpatient 664 498 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 590.96 89 999999999 517.92 630.8 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20606_1 CDM 361 RC 20606 HCPCS outpatient 664 498 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 584.32 88 999999999 517.92 630.8 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20606_1 CDM 361 RC 20606 HCPCS outpatient 664 498 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 590.96 89 999999999 517.92 630.8 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20606_50_1 CDM 361 RC 20606 HCPCS outpatient 997 747.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 897.3 999999999 777.66 947.15 case rate "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20606_50_1 CDM 361 RC 20606 HCPCS outpatient 997 747.75 AETNA MCR ADV AETNA MCR ADV 50 777.66 78 999999999 777.66 947.15 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20606_50_1 CDM 361 RC 20606 HCPCS outpatient 997 747.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 873.07 87.57 999999999 777.66 947.15 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20606_50_1 CDM 361 RC 20606 HCPCS outpatient 997 747.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 848.15 85.07 999999999 777.66 947.15 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20606_50_1 CDM 361 RC 20606 HCPCS outpatient 997 747.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 848.15 85.07 999999999 777.66 947.15 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20606_50_1 CDM 361 RC 20606 HCPCS outpatient 997 747.75 MOLINA MCAID MOLINA MCAID 50 831.5 83.4 999999999 777.66 947.15 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20606_50_1 CDM 361 RC 20606 HCPCS outpatient 997 747.75 MOLINA MCR ADV MOLINA MCR ADV 50 887.33 89 999999999 777.66 947.15 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20606_50_1 CDM 361 RC 20606 HCPCS outpatient 997 747.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 887.33 89 999999999 777.66 947.15 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20606_50_1 CDM 361 RC 20606 HCPCS outpatient 997 747.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 887.33 89 999999999 777.66 947.15 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20606_50_1 CDM 361 RC 20606 HCPCS outpatient 997 747.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 897.3 90 999999999 777.66 947.15 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20606_50_1 CDM 361 RC 20606 HCPCS outpatient 997 747.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 947.15 95 999999999 777.66 947.15 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20606_50_1 CDM 361 RC 20606 HCPCS outpatient 997 747.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 947.15 95 999999999 777.66 947.15 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20606_50_1 CDM 361 RC 20606 HCPCS outpatient 997 747.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 887.33 89 999999999 777.66 947.15 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20606_50_1 CDM 361 RC 20606 HCPCS outpatient 997 747.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 877.36 88 999999999 777.66 947.15 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20606_50_1 CDM 361 RC 20606 HCPCS outpatient 997 747.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 887.33 89 999999999 777.66 947.15 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_1 CDM 361 RC 20610 HCPCS outpatient 518 388.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 466.2 999999999 404.04 492.1 case rate "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_1 CDM 361 RC 20610 HCPCS outpatient 518 388.5 AETNA MCR ADV AETNA MCR ADV 404.04 78 999999999 404.04 492.1 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_1 CDM 361 RC 20610 HCPCS outpatient 518 388.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 453.61 87.57 999999999 404.04 492.1 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_1 CDM 361 RC 20610 HCPCS outpatient 518 388.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 440.66 85.07 999999999 404.04 492.1 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_1 CDM 361 RC 20610 HCPCS outpatient 518 388.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 440.66 85.07 999999999 404.04 492.1 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_1 CDM 361 RC 20610 HCPCS outpatient 518 388.5 MOLINA MCAID MOLINA MCAID 432.01 83.4 999999999 404.04 492.1 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_1 CDM 361 RC 20610 HCPCS outpatient 518 388.5 MOLINA MCR ADV MOLINA MCR ADV 461.02 89 999999999 404.04 492.1 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_1 CDM 361 RC 20610 HCPCS outpatient 518 388.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 461.02 89 999999999 404.04 492.1 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_1 CDM 361 RC 20610 HCPCS outpatient 518 388.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 461.02 89 999999999 404.04 492.1 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_1 CDM 361 RC 20610 HCPCS outpatient 518 388.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 466.2 90 999999999 404.04 492.1 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_1 CDM 361 RC 20610 HCPCS outpatient 518 388.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 492.1 95 999999999 404.04 492.1 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_1 CDM 361 RC 20610 HCPCS outpatient 518 388.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 492.1 95 999999999 404.04 492.1 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_1 CDM 361 RC 20610 HCPCS outpatient 518 388.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 461.02 89 999999999 404.04 492.1 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_1 CDM 361 RC 20610 HCPCS outpatient 518 388.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 455.84 88 999999999 404.04 492.1 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_1 CDM 361 RC 20610 HCPCS outpatient 518 388.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 461.02 89 999999999 404.04 492.1 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_2 CDM 361 RC 20610 HCPCS outpatient 135.51 101.63 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 121.96 999999999 105.7 128.73 case rate "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_2 CDM 361 RC 20610 HCPCS outpatient 135.51 101.63 AETNA MCR ADV AETNA MCR ADV 105.7 78 999999999 105.7 128.73 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_2 CDM 361 RC 20610 HCPCS outpatient 135.51 101.63 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 118.67 87.57 999999999 105.7 128.73 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_2 CDM 361 RC 20610 HCPCS outpatient 135.51 101.63 COORDINATED CARE MCAID COORDINATED CARE MCAID 115.28 85.07 999999999 105.7 128.73 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_2 CDM 361 RC 20610 HCPCS outpatient 135.51 101.63 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 115.28 85.07 999999999 105.7 128.73 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_2 CDM 361 RC 20610 HCPCS outpatient 135.51 101.63 MOLINA MCAID MOLINA MCAID 113.02 83.4 999999999 105.7 128.73 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_2 CDM 361 RC 20610 HCPCS outpatient 135.51 101.63 MOLINA MCR ADV MOLINA MCR ADV 120.6 89 999999999 105.7 128.73 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_2 CDM 361 RC 20610 HCPCS outpatient 135.51 101.63 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 120.6 89 999999999 105.7 128.73 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_2 CDM 361 RC 20610 HCPCS outpatient 135.51 101.63 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 120.6 89 999999999 105.7 128.73 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_2 CDM 361 RC 20610 HCPCS outpatient 135.51 101.63 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 121.96 90 999999999 105.7 128.73 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_2 CDM 361 RC 20610 HCPCS outpatient 135.51 101.63 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 128.73 95 999999999 105.7 128.73 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_2 CDM 361 RC 20610 HCPCS outpatient 135.51 101.63 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 128.73 95 999999999 105.7 128.73 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_2 CDM 361 RC 20610 HCPCS outpatient 135.51 101.63 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 120.6 89 999999999 105.7 128.73 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_2 CDM 361 RC 20610 HCPCS outpatient 135.51 101.63 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 119.25 88 999999999 105.7 128.73 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_2 CDM 361 RC 20610 HCPCS outpatient 135.51 101.63 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 120.6 89 999999999 105.7 128.73 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_3 CDM 361 RC 20610 HCPCS outpatient 135 101.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 121.5 999999999 105.3 128.25 case rate "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_3 CDM 361 RC 20610 HCPCS outpatient 135 101.25 AETNA MCR ADV AETNA MCR ADV 105.3 78 999999999 105.3 128.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_3 CDM 361 RC 20610 HCPCS outpatient 135 101.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 118.22 87.57 999999999 105.3 128.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_3 CDM 361 RC 20610 HCPCS outpatient 135 101.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 114.84 85.07 999999999 105.3 128.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_3 CDM 361 RC 20610 HCPCS outpatient 135 101.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 114.84 85.07 999999999 105.3 128.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_3 CDM 361 RC 20610 HCPCS outpatient 135 101.25 MOLINA MCAID MOLINA MCAID 112.59 83.4 999999999 105.3 128.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_3 CDM 361 RC 20610 HCPCS outpatient 135 101.25 MOLINA MCR ADV MOLINA MCR ADV 120.15 89 999999999 105.3 128.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_3 CDM 361 RC 20610 HCPCS outpatient 135 101.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 120.15 89 999999999 105.3 128.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_3 CDM 361 RC 20610 HCPCS outpatient 135 101.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 120.15 89 999999999 105.3 128.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_3 CDM 361 RC 20610 HCPCS outpatient 135 101.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 121.5 90 999999999 105.3 128.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_3 CDM 361 RC 20610 HCPCS outpatient 135 101.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 128.25 95 999999999 105.3 128.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_3 CDM 361 RC 20610 HCPCS outpatient 135 101.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 128.25 95 999999999 105.3 128.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_3 CDM 361 RC 20610 HCPCS outpatient 135 101.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 120.15 89 999999999 105.3 128.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_3 CDM 361 RC 20610 HCPCS outpatient 135 101.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 118.8 88 999999999 105.3 128.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_3 CDM 361 RC 20610 HCPCS outpatient 135 101.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 120.15 89 999999999 105.3 128.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50 CDM 361 RC 20610 HCPCS inpatient 135 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50 CDM 361 RC 20610 HCPCS inpatient 135 AETNA MCR ADV AETNA MCR ADV 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50 CDM 361 RC 20610 HCPCS inpatient 135 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50 CDM 361 RC 20610 HCPCS inpatient 135 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50 CDM 361 RC 20610 HCPCS inpatient 135 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50 CDM 361 RC 20610 HCPCS inpatient 135 MOLINA MCAID MOLINA MCAID 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50 CDM 361 RC 20610 HCPCS inpatient 135 MOLINA MCR ADV MOLINA MCR ADV 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50 CDM 361 RC 20610 HCPCS inpatient 135 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50 CDM 361 RC 20610 HCPCS inpatient 135 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50 CDM 361 RC 20610 HCPCS inpatient 135 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50 CDM 361 RC 20610 HCPCS inpatient 135 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50 CDM 361 RC 20610 HCPCS inpatient 135 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50 CDM 361 RC 20610 HCPCS inpatient 135 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50 CDM 361 RC 20610 HCPCS inpatient 135 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50 CDM 361 RC 20610 HCPCS inpatient 135 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50 CDM 361 RC 20610 HCPCS inpatient 777 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50 CDM 361 RC 20610 HCPCS inpatient 777 AETNA MCR ADV AETNA MCR ADV 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50 CDM 361 RC 20610 HCPCS inpatient 777 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50 CDM 361 RC 20610 HCPCS inpatient 777 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50 CDM 361 RC 20610 HCPCS inpatient 777 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50 CDM 361 RC 20610 HCPCS inpatient 777 MOLINA MCAID MOLINA MCAID 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50 CDM 361 RC 20610 HCPCS inpatient 777 MOLINA MCR ADV MOLINA MCR ADV 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50 CDM 361 RC 20610 HCPCS inpatient 777 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50 CDM 361 RC 20610 HCPCS inpatient 777 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50 CDM 361 RC 20610 HCPCS inpatient 777 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50 CDM 361 RC 20610 HCPCS inpatient 777 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50 CDM 361 RC 20610 HCPCS inpatient 777 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50 CDM 361 RC 20610 HCPCS inpatient 777 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50 CDM 361 RC 20610 HCPCS inpatient 777 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50 CDM 361 RC 20610 HCPCS inpatient 777 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50_1 CDM 361 RC 20610 HCPCS outpatient 777 582.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 699.3 999999999 606.06 738.15 case rate "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50_1 CDM 361 RC 20610 HCPCS outpatient 777 582.75 AETNA MCR ADV AETNA MCR ADV 50 606.06 78 999999999 606.06 738.15 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50_1 CDM 361 RC 20610 HCPCS outpatient 777 582.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 680.42 87.57 999999999 606.06 738.15 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50_1 CDM 361 RC 20610 HCPCS outpatient 777 582.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 660.99 85.07 999999999 606.06 738.15 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50_1 CDM 361 RC 20610 HCPCS outpatient 777 582.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 660.99 85.07 999999999 606.06 738.15 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50_1 CDM 361 RC 20610 HCPCS outpatient 777 582.75 MOLINA MCAID MOLINA MCAID 50 648.02 83.4 999999999 606.06 738.15 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50_1 CDM 361 RC 20610 HCPCS outpatient 777 582.75 MOLINA MCR ADV MOLINA MCR ADV 50 691.53 89 999999999 606.06 738.15 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50_1 CDM 361 RC 20610 HCPCS outpatient 777 582.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 691.53 89 999999999 606.06 738.15 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50_1 CDM 361 RC 20610 HCPCS outpatient 777 582.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 691.53 89 999999999 606.06 738.15 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50_1 CDM 361 RC 20610 HCPCS outpatient 777 582.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 699.3 90 999999999 606.06 738.15 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50_1 CDM 361 RC 20610 HCPCS outpatient 777 582.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 738.15 95 999999999 606.06 738.15 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50_1 CDM 361 RC 20610 HCPCS outpatient 777 582.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 738.15 95 999999999 606.06 738.15 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50_1 CDM 361 RC 20610 HCPCS outpatient 777 582.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 691.53 89 999999999 606.06 738.15 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50_1 CDM 361 RC 20610 HCPCS outpatient 777 582.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 683.76 88 999999999 606.06 738.15 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 20610_50_1 CDM 361 RC 20610 HCPCS outpatient 777 582.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 691.53 89 999999999 606.06 738.15 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_1 CDM 360 RC 20611 HCPCS outpatient 616 462 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 554.4 999999999 480.48 585.2 case rate "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_1 CDM 360 RC 20611 HCPCS outpatient 616 462 AETNA MCR ADV AETNA MCR ADV 480.48 78 999999999 480.48 585.2 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_1 CDM 360 RC 20611 HCPCS outpatient 616 462 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 539.43 87.57 999999999 480.48 585.2 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_1 CDM 360 RC 20611 HCPCS outpatient 616 462 COORDINATED CARE MCAID COORDINATED CARE MCAID 524.03 85.07 999999999 480.48 585.2 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_1 CDM 360 RC 20611 HCPCS outpatient 616 462 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 524.03 85.07 999999999 480.48 585.2 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_1 CDM 360 RC 20611 HCPCS outpatient 616 462 MOLINA MCAID MOLINA MCAID 513.74 83.4 999999999 480.48 585.2 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_1 CDM 360 RC 20611 HCPCS outpatient 616 462 MOLINA MCR ADV MOLINA MCR ADV 548.24 89 999999999 480.48 585.2 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_1 CDM 360 RC 20611 HCPCS outpatient 616 462 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 548.24 89 999999999 480.48 585.2 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_1 CDM 360 RC 20611 HCPCS outpatient 616 462 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 548.24 89 999999999 480.48 585.2 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_1 CDM 360 RC 20611 HCPCS outpatient 616 462 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 554.4 90 999999999 480.48 585.2 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_1 CDM 360 RC 20611 HCPCS outpatient 616 462 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 585.2 95 999999999 480.48 585.2 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_1 CDM 360 RC 20611 HCPCS outpatient 616 462 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 585.2 95 999999999 480.48 585.2 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_1 CDM 360 RC 20611 HCPCS outpatient 616 462 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 548.24 89 999999999 480.48 585.2 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_1 CDM 360 RC 20611 HCPCS outpatient 616 462 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 542.08 88 999999999 480.48 585.2 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_1 CDM 360 RC 20611 HCPCS outpatient 616 462 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 548.24 89 999999999 480.48 585.2 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_50 CDM 360 RC 20611 HCPCS inpatient 923 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_50 CDM 360 RC 20611 HCPCS inpatient 923 AETNA MCR ADV AETNA MCR ADV 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_50 CDM 360 RC 20611 HCPCS inpatient 923 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_50 CDM 360 RC 20611 HCPCS inpatient 923 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_50 CDM 360 RC 20611 HCPCS inpatient 923 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_50 CDM 360 RC 20611 HCPCS inpatient 923 MOLINA MCAID MOLINA MCAID 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_50 CDM 360 RC 20611 HCPCS inpatient 923 MOLINA MCR ADV MOLINA MCR ADV 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_50 CDM 360 RC 20611 HCPCS inpatient 923 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_50 CDM 360 RC 20611 HCPCS inpatient 923 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_50 CDM 360 RC 20611 HCPCS inpatient 923 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_50 CDM 360 RC 20611 HCPCS inpatient 923 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_50 CDM 360 RC 20611 HCPCS inpatient 923 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_50 CDM 360 RC 20611 HCPCS inpatient 923 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_50 CDM 360 RC 20611 HCPCS inpatient 923 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_50 CDM 360 RC 20611 HCPCS inpatient 923 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 999999999 "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_50_1 CDM 360 RC 20611 HCPCS outpatient 923 692.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 830.7 999999999 719.94 876.85 case rate "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_50_1 CDM 360 RC 20611 HCPCS outpatient 923 692.25 AETNA MCR ADV AETNA MCR ADV 50 719.94 78 999999999 719.94 876.85 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_50_1 CDM 360 RC 20611 HCPCS outpatient 923 692.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 808.27 87.57 999999999 719.94 876.85 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_50_1 CDM 360 RC 20611 HCPCS outpatient 923 692.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 785.2 85.07 999999999 719.94 876.85 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_50_1 CDM 360 RC 20611 HCPCS outpatient 923 692.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 785.2 85.07 999999999 719.94 876.85 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_50_1 CDM 360 RC 20611 HCPCS outpatient 923 692.25 MOLINA MCAID MOLINA MCAID 50 769.78 83.4 999999999 719.94 876.85 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_50_1 CDM 360 RC 20611 HCPCS outpatient 923 692.25 MOLINA MCR ADV MOLINA MCR ADV 50 821.47 89 999999999 719.94 876.85 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_50_1 CDM 360 RC 20611 HCPCS outpatient 923 692.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 821.47 89 999999999 719.94 876.85 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_50_1 CDM 360 RC 20611 HCPCS outpatient 923 692.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 821.47 89 999999999 719.94 876.85 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_50_1 CDM 360 RC 20611 HCPCS outpatient 923 692.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 830.7 90 999999999 719.94 876.85 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_50_1 CDM 360 RC 20611 HCPCS outpatient 923 692.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 876.85 95 999999999 719.94 876.85 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_50_1 CDM 360 RC 20611 HCPCS outpatient 923 692.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 876.85 95 999999999 719.94 876.85 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_50_1 CDM 360 RC 20611 HCPCS outpatient 923 692.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 821.47 89 999999999 719.94 876.85 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_50_1 CDM 360 RC 20611 HCPCS outpatient 923 692.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 812.24 88 999999999 719.94 876.85 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 20611_50_1 CDM 360 RC 20611 HCPCS outpatient 923 692.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 821.47 89 999999999 719.94 876.85 percent of total billed charges ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION 20612_3 CDM 360 RC 20612 HCPCS outpatient 130 97.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 117 999999999 101.4 123.5 case rate ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION 20612_3 CDM 360 RC 20612 HCPCS outpatient 130 97.5 AETNA MCR ADV AETNA MCR ADV 101.4 78 999999999 101.4 123.5 percent of total billed charges ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION 20612_3 CDM 360 RC 20612 HCPCS outpatient 130 97.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 113.84 87.57 999999999 101.4 123.5 percent of total billed charges ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION 20612_3 CDM 360 RC 20612 HCPCS outpatient 130 97.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 110.59 85.07 999999999 101.4 123.5 percent of total billed charges ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION 20612_3 CDM 360 RC 20612 HCPCS outpatient 130 97.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 110.59 85.07 999999999 101.4 123.5 percent of total billed charges ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION 20612_3 CDM 360 RC 20612 HCPCS outpatient 130 97.5 MOLINA MCAID MOLINA MCAID 108.42 83.4 999999999 101.4 123.5 percent of total billed charges ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION 20612_3 CDM 360 RC 20612 HCPCS outpatient 130 97.5 MOLINA MCR ADV MOLINA MCR ADV 115.7 89 999999999 101.4 123.5 percent of total billed charges ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION 20612_3 CDM 360 RC 20612 HCPCS outpatient 130 97.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 115.7 89 999999999 101.4 123.5 percent of total billed charges ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION 20612_3 CDM 360 RC 20612 HCPCS outpatient 130 97.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 115.7 89 999999999 101.4 123.5 percent of total billed charges ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION 20612_3 CDM 360 RC 20612 HCPCS outpatient 130 97.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 117 90 999999999 101.4 123.5 percent of total billed charges ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION 20612_3 CDM 360 RC 20612 HCPCS outpatient 130 97.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 123.5 95 999999999 101.4 123.5 percent of total billed charges ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION 20612_3 CDM 360 RC 20612 HCPCS outpatient 130 97.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 123.5 95 999999999 101.4 123.5 percent of total billed charges ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION 20612_3 CDM 360 RC 20612 HCPCS outpatient 130 97.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 115.7 89 999999999 101.4 123.5 percent of total billed charges ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION 20612_3 CDM 360 RC 20612 HCPCS outpatient 130 97.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 114.4 88 999999999 101.4 123.5 percent of total billed charges ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION 20612_3 CDM 360 RC 20612 HCPCS outpatient 130 97.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 115.7 89 999999999 101.4 123.5 percent of total billed charges CLOSED TREATMENT OF MANDIBULAR OR MAXILLARY ALVEOLAR RIDGE FRACTURE (SEPARATE PROCEDURE) 21440_3 CDM 360 RC 21440 HCPCS outpatient 1446 1084.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1301.4 999999999 1127.88 1373.7 case rate CLOSED TREATMENT OF MANDIBULAR OR MAXILLARY ALVEOLAR RIDGE FRACTURE (SEPARATE PROCEDURE) 21440_3 CDM 360 RC 21440 HCPCS outpatient 1446 1084.5 AETNA MCR ADV AETNA MCR ADV 1127.88 78 999999999 1127.88 1373.7 percent of total billed charges CLOSED TREATMENT OF MANDIBULAR OR MAXILLARY ALVEOLAR RIDGE FRACTURE (SEPARATE PROCEDURE) 21440_3 CDM 360 RC 21440 HCPCS outpatient 1446 1084.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1266.26 87.57 999999999 1127.88 1373.7 percent of total billed charges CLOSED TREATMENT OF MANDIBULAR OR MAXILLARY ALVEOLAR RIDGE FRACTURE (SEPARATE PROCEDURE) 21440_3 CDM 360 RC 21440 HCPCS outpatient 1446 1084.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 1230.11 85.07 999999999 1127.88 1373.7 percent of total billed charges CLOSED TREATMENT OF MANDIBULAR OR MAXILLARY ALVEOLAR RIDGE FRACTURE (SEPARATE PROCEDURE) 21440_3 CDM 360 RC 21440 HCPCS outpatient 1446 1084.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1230.11 85.07 999999999 1127.88 1373.7 percent of total billed charges CLOSED TREATMENT OF MANDIBULAR OR MAXILLARY ALVEOLAR RIDGE FRACTURE (SEPARATE PROCEDURE) 21440_3 CDM 360 RC 21440 HCPCS outpatient 1446 1084.5 MOLINA MCAID MOLINA MCAID 1205.96 83.4 999999999 1127.88 1373.7 percent of total billed charges CLOSED TREATMENT OF MANDIBULAR OR MAXILLARY ALVEOLAR RIDGE FRACTURE (SEPARATE PROCEDURE) 21440_3 CDM 360 RC 21440 HCPCS outpatient 1446 1084.5 MOLINA MCR ADV MOLINA MCR ADV 1286.94 89 999999999 1127.88 1373.7 percent of total billed charges CLOSED TREATMENT OF MANDIBULAR OR MAXILLARY ALVEOLAR RIDGE FRACTURE (SEPARATE PROCEDURE) 21440_3 CDM 360 RC 21440 HCPCS outpatient 1446 1084.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1286.94 89 999999999 1127.88 1373.7 percent of total billed charges CLOSED TREATMENT OF MANDIBULAR OR MAXILLARY ALVEOLAR RIDGE FRACTURE (SEPARATE PROCEDURE) 21440_3 CDM 360 RC 21440 HCPCS outpatient 1446 1084.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1286.94 89 999999999 1127.88 1373.7 percent of total billed charges CLOSED TREATMENT OF MANDIBULAR OR MAXILLARY ALVEOLAR RIDGE FRACTURE (SEPARATE PROCEDURE) 21440_3 CDM 360 RC 21440 HCPCS outpatient 1446 1084.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1301.4 90 999999999 1127.88 1373.7 percent of total billed charges CLOSED TREATMENT OF MANDIBULAR OR MAXILLARY ALVEOLAR RIDGE FRACTURE (SEPARATE PROCEDURE) 21440_3 CDM 360 RC 21440 HCPCS outpatient 1446 1084.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1373.7 95 999999999 1127.88 1373.7 percent of total billed charges CLOSED TREATMENT OF MANDIBULAR OR MAXILLARY ALVEOLAR RIDGE FRACTURE (SEPARATE PROCEDURE) 21440_3 CDM 360 RC 21440 HCPCS outpatient 1446 1084.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1373.7 95 999999999 1127.88 1373.7 percent of total billed charges CLOSED TREATMENT OF MANDIBULAR OR MAXILLARY ALVEOLAR RIDGE FRACTURE (SEPARATE PROCEDURE) 21440_3 CDM 360 RC 21440 HCPCS outpatient 1446 1084.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1286.94 89 999999999 1127.88 1373.7 percent of total billed charges CLOSED TREATMENT OF MANDIBULAR OR MAXILLARY ALVEOLAR RIDGE FRACTURE (SEPARATE PROCEDURE) 21440_3 CDM 360 RC 21440 HCPCS outpatient 1446 1084.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1272.48 88 999999999 1127.88 1373.7 percent of total billed charges CLOSED TREATMENT OF MANDIBULAR OR MAXILLARY ALVEOLAR RIDGE FRACTURE (SEPARATE PROCEDURE) 21440_3 CDM 360 RC 21440 HCPCS outpatient 1446 1084.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1286.94 89 999999999 1127.88 1373.7 percent of total billed charges CLOSED TREATMENT OF MANDIBULAR FRACTURE; WITH MANIPULATION 21451_3 CDM 360 RC 21451 HCPCS outpatient 1612 1209 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1450.8 999999999 1257.36 1531.4 case rate CLOSED TREATMENT OF MANDIBULAR FRACTURE; WITH MANIPULATION 21451_3 CDM 360 RC 21451 HCPCS outpatient 1612 1209 AETNA MCR ADV AETNA MCR ADV 1257.36 78 999999999 1257.36 1531.4 percent of total billed charges CLOSED TREATMENT OF MANDIBULAR FRACTURE; WITH MANIPULATION 21451_3 CDM 360 RC 21451 HCPCS outpatient 1612 1209 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1411.63 87.57 999999999 1257.36 1531.4 percent of total billed charges CLOSED TREATMENT OF MANDIBULAR FRACTURE; WITH MANIPULATION 21451_3 CDM 360 RC 21451 HCPCS outpatient 1612 1209 COORDINATED CARE MCAID COORDINATED CARE MCAID 1371.33 85.07 999999999 1257.36 1531.4 percent of total billed charges CLOSED TREATMENT OF MANDIBULAR FRACTURE; WITH MANIPULATION 21451_3 CDM 360 RC 21451 HCPCS outpatient 1612 1209 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1371.33 85.07 999999999 1257.36 1531.4 percent of total billed charges CLOSED TREATMENT OF MANDIBULAR FRACTURE; WITH MANIPULATION 21451_3 CDM 360 RC 21451 HCPCS outpatient 1612 1209 MOLINA MCAID MOLINA MCAID 1344.41 83.4 999999999 1257.36 1531.4 percent of total billed charges CLOSED TREATMENT OF MANDIBULAR FRACTURE; WITH MANIPULATION 21451_3 CDM 360 RC 21451 HCPCS outpatient 1612 1209 MOLINA MCR ADV MOLINA MCR ADV 1434.68 89 999999999 1257.36 1531.4 percent of total billed charges CLOSED TREATMENT OF MANDIBULAR FRACTURE; WITH MANIPULATION 21451_3 CDM 360 RC 21451 HCPCS outpatient 1612 1209 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1434.68 89 999999999 1257.36 1531.4 percent of total billed charges CLOSED TREATMENT OF MANDIBULAR FRACTURE; WITH MANIPULATION 21451_3 CDM 360 RC 21451 HCPCS outpatient 1612 1209 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1434.68 89 999999999 1257.36 1531.4 percent of total billed charges CLOSED TREATMENT OF MANDIBULAR FRACTURE; WITH MANIPULATION 21451_3 CDM 360 RC 21451 HCPCS outpatient 1612 1209 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1450.8 90 999999999 1257.36 1531.4 percent of total billed charges CLOSED TREATMENT OF MANDIBULAR FRACTURE; WITH MANIPULATION 21451_3 CDM 360 RC 21451 HCPCS outpatient 1612 1209 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1531.4 95 999999999 1257.36 1531.4 percent of total billed charges CLOSED TREATMENT OF MANDIBULAR FRACTURE; WITH MANIPULATION 21451_3 CDM 360 RC 21451 HCPCS outpatient 1612 1209 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1531.4 95 999999999 1257.36 1531.4 percent of total billed charges CLOSED TREATMENT OF MANDIBULAR FRACTURE; WITH MANIPULATION 21451_3 CDM 360 RC 21451 HCPCS outpatient 1612 1209 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1434.68 89 999999999 1257.36 1531.4 percent of total billed charges CLOSED TREATMENT OF MANDIBULAR FRACTURE; WITH MANIPULATION 21451_3 CDM 360 RC 21451 HCPCS outpatient 1612 1209 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1418.56 88 999999999 1257.36 1531.4 percent of total billed charges CLOSED TREATMENT OF MANDIBULAR FRACTURE; WITH MANIPULATION 21451_3 CDM 360 RC 21451 HCPCS outpatient 1612 1209 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1434.68 89 999999999 1257.36 1531.4 percent of total billed charges CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT 21480_1 CDM 360 RC 21480 HCPCS outpatient 91.83 68.87 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 82.65 999999999 71.63 87.24 case rate CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT 21480_1 CDM 360 RC 21480 HCPCS outpatient 91.83 68.87 AETNA MCR ADV AETNA MCR ADV 71.63 78 999999999 71.63 87.24 percent of total billed charges CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT 21480_1 CDM 360 RC 21480 HCPCS outpatient 91.83 68.87 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 80.42 87.57 999999999 71.63 87.24 percent of total billed charges CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT 21480_1 CDM 360 RC 21480 HCPCS outpatient 91.83 68.87 COORDINATED CARE MCAID COORDINATED CARE MCAID 78.12 85.07 999999999 71.63 87.24 percent of total billed charges CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT 21480_1 CDM 360 RC 21480 HCPCS outpatient 91.83 68.87 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 78.12 85.07 999999999 71.63 87.24 percent of total billed charges CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT 21480_1 CDM 360 RC 21480 HCPCS outpatient 91.83 68.87 MOLINA MCAID MOLINA MCAID 76.59 83.4 999999999 71.63 87.24 percent of total billed charges CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT 21480_1 CDM 360 RC 21480 HCPCS outpatient 91.83 68.87 MOLINA MCR ADV MOLINA MCR ADV 81.73 89 999999999 71.63 87.24 percent of total billed charges CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT 21480_1 CDM 360 RC 21480 HCPCS outpatient 91.83 68.87 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 81.73 89 999999999 71.63 87.24 percent of total billed charges CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT 21480_1 CDM 360 RC 21480 HCPCS outpatient 91.83 68.87 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 81.73 89 999999999 71.63 87.24 percent of total billed charges CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT 21480_1 CDM 360 RC 21480 HCPCS outpatient 91.83 68.87 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 82.65 90 999999999 71.63 87.24 percent of total billed charges CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT 21480_1 CDM 360 RC 21480 HCPCS outpatient 91.83 68.87 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 87.24 95 999999999 71.63 87.24 percent of total billed charges CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT 21480_1 CDM 360 RC 21480 HCPCS outpatient 91.83 68.87 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 87.24 95 999999999 71.63 87.24 percent of total billed charges CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT 21480_1 CDM 360 RC 21480 HCPCS outpatient 91.83 68.87 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 81.73 89 999999999 71.63 87.24 percent of total billed charges CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT 21480_1 CDM 360 RC 21480 HCPCS outpatient 91.83 68.87 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 80.81 88 999999999 71.63 87.24 percent of total billed charges CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT 21480_1 CDM 360 RC 21480 HCPCS outpatient 91.83 68.87 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 81.73 89 999999999 71.63 87.24 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_1 CDM 360 RC 23650 HCPCS outpatient 910.29 682.72 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 819.26 999999999 710.03 864.78 case rate "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_1 CDM 360 RC 23650 HCPCS outpatient 910.29 682.72 AETNA MCR ADV AETNA MCR ADV 710.03 78 999999999 710.03 864.78 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_1 CDM 360 RC 23650 HCPCS outpatient 910.29 682.72 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 797.14 87.57 999999999 710.03 864.78 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_1 CDM 360 RC 23650 HCPCS outpatient 910.29 682.72 COORDINATED CARE MCAID COORDINATED CARE MCAID 774.38 85.07 999999999 710.03 864.78 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_1 CDM 360 RC 23650 HCPCS outpatient 910.29 682.72 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 774.38 85.07 999999999 710.03 864.78 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_1 CDM 360 RC 23650 HCPCS outpatient 910.29 682.72 MOLINA MCAID MOLINA MCAID 759.18 83.4 999999999 710.03 864.78 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_1 CDM 360 RC 23650 HCPCS outpatient 910.29 682.72 MOLINA MCR ADV MOLINA MCR ADV 810.16 89 999999999 710.03 864.78 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_1 CDM 360 RC 23650 HCPCS outpatient 910.29 682.72 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 810.16 89 999999999 710.03 864.78 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_1 CDM 360 RC 23650 HCPCS outpatient 910.29 682.72 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 810.16 89 999999999 710.03 864.78 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_1 CDM 360 RC 23650 HCPCS outpatient 910.29 682.72 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 819.26 90 999999999 710.03 864.78 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_1 CDM 360 RC 23650 HCPCS outpatient 910.29 682.72 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 864.78 95 999999999 710.03 864.78 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_1 CDM 360 RC 23650 HCPCS outpatient 910.29 682.72 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 864.78 95 999999999 710.03 864.78 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_1 CDM 360 RC 23650 HCPCS outpatient 910.29 682.72 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 810.16 89 999999999 710.03 864.78 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_1 CDM 360 RC 23650 HCPCS outpatient 910.29 682.72 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 801.06 88 999999999 710.03 864.78 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_1 CDM 360 RC 23650 HCPCS outpatient 910.29 682.72 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 810.16 89 999999999 710.03 864.78 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_2 CDM 360 RC 23650 HCPCS outpatient 910.29 682.72 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 819.26 999999999 710.03 864.78 case rate "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_2 CDM 360 RC 23650 HCPCS outpatient 910.29 682.72 AETNA MCR ADV AETNA MCR ADV 710.03 78 999999999 710.03 864.78 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_2 CDM 360 RC 23650 HCPCS outpatient 910.29 682.72 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 797.14 87.57 999999999 710.03 864.78 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_2 CDM 360 RC 23650 HCPCS outpatient 910.29 682.72 COORDINATED CARE MCAID COORDINATED CARE MCAID 774.38 85.07 999999999 710.03 864.78 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_2 CDM 360 RC 23650 HCPCS outpatient 910.29 682.72 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 774.38 85.07 999999999 710.03 864.78 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_2 CDM 360 RC 23650 HCPCS outpatient 910.29 682.72 MOLINA MCAID MOLINA MCAID 759.18 83.4 999999999 710.03 864.78 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_2 CDM 360 RC 23650 HCPCS outpatient 910.29 682.72 MOLINA MCR ADV MOLINA MCR ADV 810.16 89 999999999 710.03 864.78 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_2 CDM 360 RC 23650 HCPCS outpatient 910.29 682.72 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 810.16 89 999999999 710.03 864.78 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_2 CDM 360 RC 23650 HCPCS outpatient 910.29 682.72 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 810.16 89 999999999 710.03 864.78 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_2 CDM 360 RC 23650 HCPCS outpatient 910.29 682.72 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 819.26 90 999999999 710.03 864.78 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_2 CDM 360 RC 23650 HCPCS outpatient 910.29 682.72 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 864.78 95 999999999 710.03 864.78 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_2 CDM 360 RC 23650 HCPCS outpatient 910.29 682.72 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 864.78 95 999999999 710.03 864.78 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_2 CDM 360 RC 23650 HCPCS outpatient 910.29 682.72 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 810.16 89 999999999 710.03 864.78 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_2 CDM 360 RC 23650 HCPCS outpatient 910.29 682.72 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 801.06 88 999999999 710.03 864.78 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_2 CDM 360 RC 23650 HCPCS outpatient 910.29 682.72 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 810.16 89 999999999 710.03 864.78 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_3 CDM 360 RC 23650 HCPCS outpatient 672 504 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 604.8 999999999 524.16 638.4 case rate "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_3 CDM 360 RC 23650 HCPCS outpatient 672 504 AETNA MCR ADV AETNA MCR ADV 524.16 78 999999999 524.16 638.4 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_3 CDM 360 RC 23650 HCPCS outpatient 672 504 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 588.47 87.57 999999999 524.16 638.4 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_3 CDM 360 RC 23650 HCPCS outpatient 672 504 COORDINATED CARE MCAID COORDINATED CARE MCAID 571.67 85.07 999999999 524.16 638.4 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_3 CDM 360 RC 23650 HCPCS outpatient 672 504 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 571.67 85.07 999999999 524.16 638.4 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_3 CDM 360 RC 23650 HCPCS outpatient 672 504 MOLINA MCAID MOLINA MCAID 560.45 83.4 999999999 524.16 638.4 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_3 CDM 360 RC 23650 HCPCS outpatient 672 504 MOLINA MCR ADV MOLINA MCR ADV 598.08 89 999999999 524.16 638.4 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_3 CDM 360 RC 23650 HCPCS outpatient 672 504 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 598.08 89 999999999 524.16 638.4 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_3 CDM 360 RC 23650 HCPCS outpatient 672 504 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 598.08 89 999999999 524.16 638.4 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_3 CDM 360 RC 23650 HCPCS outpatient 672 504 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 604.8 90 999999999 524.16 638.4 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_3 CDM 360 RC 23650 HCPCS outpatient 672 504 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 638.4 95 999999999 524.16 638.4 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_3 CDM 360 RC 23650 HCPCS outpatient 672 504 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 638.4 95 999999999 524.16 638.4 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_3 CDM 360 RC 23650 HCPCS outpatient 672 504 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 598.08 89 999999999 524.16 638.4 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_3 CDM 360 RC 23650 HCPCS outpatient 672 504 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 591.36 88 999999999 524.16 638.4 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 23650_3 CDM 360 RC 23650 HCPCS outpatient 672 504 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 598.08 89 999999999 524.16 638.4 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 23655_1 CDM 360 RC 23655 HCPCS outpatient 1258.14 943.61 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1132.33 999999999 981.35 1195.23 case rate "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 23655_1 CDM 360 RC 23655 HCPCS outpatient 1258.14 943.61 AETNA MCR ADV AETNA MCR ADV 981.35 78 999999999 981.35 1195.23 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 23655_1 CDM 360 RC 23655 HCPCS outpatient 1258.14 943.61 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1101.75 87.57 999999999 981.35 1195.23 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 23655_1 CDM 360 RC 23655 HCPCS outpatient 1258.14 943.61 COORDINATED CARE MCAID COORDINATED CARE MCAID 1070.3 85.07 999999999 981.35 1195.23 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 23655_1 CDM 360 RC 23655 HCPCS outpatient 1258.14 943.61 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1070.3 85.07 999999999 981.35 1195.23 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 23655_1 CDM 360 RC 23655 HCPCS outpatient 1258.14 943.61 MOLINA MCAID MOLINA MCAID 1049.29 83.4 999999999 981.35 1195.23 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 23655_1 CDM 360 RC 23655 HCPCS outpatient 1258.14 943.61 MOLINA MCR ADV MOLINA MCR ADV 1119.74 89 999999999 981.35 1195.23 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 23655_1 CDM 360 RC 23655 HCPCS outpatient 1258.14 943.61 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1119.74 89 999999999 981.35 1195.23 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 23655_1 CDM 360 RC 23655 HCPCS outpatient 1258.14 943.61 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1119.74 89 999999999 981.35 1195.23 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 23655_1 CDM 360 RC 23655 HCPCS outpatient 1258.14 943.61 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1132.33 90 999999999 981.35 1195.23 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 23655_1 CDM 360 RC 23655 HCPCS outpatient 1258.14 943.61 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1195.23 95 999999999 981.35 1195.23 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 23655_1 CDM 360 RC 23655 HCPCS outpatient 1258.14 943.61 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1195.23 95 999999999 981.35 1195.23 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 23655_1 CDM 360 RC 23655 HCPCS outpatient 1258.14 943.61 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1119.74 89 999999999 981.35 1195.23 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 23655_1 CDM 360 RC 23655 HCPCS outpatient 1258.14 943.61 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1107.16 88 999999999 981.35 1195.23 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 23655_1 CDM 360 RC 23655 HCPCS outpatient 1258.14 943.61 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1119.74 89 999999999 981.35 1195.23 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 23655_3 CDM 360 RC 23655 HCPCS outpatient 840 630 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 756 999999999 655.2 798 case rate "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 23655_3 CDM 360 RC 23655 HCPCS outpatient 840 630 AETNA MCR ADV AETNA MCR ADV 655.2 78 999999999 655.2 798 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 23655_3 CDM 360 RC 23655 HCPCS outpatient 840 630 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 735.59 87.57 999999999 655.2 798 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 23655_3 CDM 360 RC 23655 HCPCS outpatient 840 630 COORDINATED CARE MCAID COORDINATED CARE MCAID 714.59 85.07 999999999 655.2 798 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 23655_3 CDM 360 RC 23655 HCPCS outpatient 840 630 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 714.59 85.07 999999999 655.2 798 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 23655_3 CDM 360 RC 23655 HCPCS outpatient 840 630 MOLINA MCAID MOLINA MCAID 700.56 83.4 999999999 655.2 798 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 23655_3 CDM 360 RC 23655 HCPCS outpatient 840 630 MOLINA MCR ADV MOLINA MCR ADV 747.6 89 999999999 655.2 798 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 23655_3 CDM 360 RC 23655 HCPCS outpatient 840 630 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 747.6 89 999999999 655.2 798 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 23655_3 CDM 360 RC 23655 HCPCS outpatient 840 630 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 747.6 89 999999999 655.2 798 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 23655_3 CDM 360 RC 23655 HCPCS outpatient 840 630 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 756 90 999999999 655.2 798 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 23655_3 CDM 360 RC 23655 HCPCS outpatient 840 630 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 798 95 999999999 655.2 798 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 23655_3 CDM 360 RC 23655 HCPCS outpatient 840 630 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 798 95 999999999 655.2 798 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 23655_3 CDM 360 RC 23655 HCPCS outpatient 840 630 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 747.6 89 999999999 655.2 798 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 23655_3 CDM 360 RC 23655 HCPCS outpatient 840 630 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 739.2 88 999999999 655.2 798 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 23655_3 CDM 360 RC 23655 HCPCS outpatient 840 630 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 747.6 89 999999999 655.2 798 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS" 24200_1 CDM 360 RC 24200 HCPCS outpatient 430.53 322.9 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 387.48 999999999 335.81 409 case rate "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS" 24200_1 CDM 360 RC 24200 HCPCS outpatient 430.53 322.9 AETNA MCR ADV AETNA MCR ADV 335.81 78 999999999 335.81 409 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS" 24200_1 CDM 360 RC 24200 HCPCS outpatient 430.53 322.9 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 377.02 87.57 999999999 335.81 409 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS" 24200_1 CDM 360 RC 24200 HCPCS outpatient 430.53 322.9 COORDINATED CARE MCAID COORDINATED CARE MCAID 366.25 85.07 999999999 335.81 409 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS" 24200_1 CDM 360 RC 24200 HCPCS outpatient 430.53 322.9 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 366.25 85.07 999999999 335.81 409 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS" 24200_1 CDM 360 RC 24200 HCPCS outpatient 430.53 322.9 MOLINA MCAID MOLINA MCAID 359.06 83.4 999999999 335.81 409 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS" 24200_1 CDM 360 RC 24200 HCPCS outpatient 430.53 322.9 MOLINA MCR ADV MOLINA MCR ADV 383.17 89 999999999 335.81 409 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS" 24200_1 CDM 360 RC 24200 HCPCS outpatient 430.53 322.9 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 383.17 89 999999999 335.81 409 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS" 24200_1 CDM 360 RC 24200 HCPCS outpatient 430.53 322.9 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 383.17 89 999999999 335.81 409 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS" 24200_1 CDM 360 RC 24200 HCPCS outpatient 430.53 322.9 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 387.48 90 999999999 335.81 409 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS" 24200_1 CDM 360 RC 24200 HCPCS outpatient 430.53 322.9 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 409 95 999999999 335.81 409 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS" 24200_1 CDM 360 RC 24200 HCPCS outpatient 430.53 322.9 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 409 95 999999999 335.81 409 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS" 24200_1 CDM 360 RC 24200 HCPCS outpatient 430.53 322.9 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 383.17 89 999999999 335.81 409 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS" 24200_1 CDM 360 RC 24200 HCPCS outpatient 430.53 322.9 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 378.87 88 999999999 335.81 409 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS" 24200_1 CDM 360 RC 24200 HCPCS outpatient 430.53 322.9 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 383.17 89 999999999 335.81 409 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 24201_1 CDM 360 RC 24201 HCPCS outpatient 1114.14 835.61 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1002.73 999999999 869.03 1058.43 case rate "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 24201_1 CDM 360 RC 24201 HCPCS outpatient 1114.14 835.61 AETNA MCR ADV AETNA MCR ADV 869.03 78 999999999 869.03 1058.43 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 24201_1 CDM 360 RC 24201 HCPCS outpatient 1114.14 835.61 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 975.65 87.57 999999999 869.03 1058.43 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 24201_1 CDM 360 RC 24201 HCPCS outpatient 1114.14 835.61 COORDINATED CARE MCAID COORDINATED CARE MCAID 947.8 85.07 999999999 869.03 1058.43 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 24201_1 CDM 360 RC 24201 HCPCS outpatient 1114.14 835.61 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 947.8 85.07 999999999 869.03 1058.43 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 24201_1 CDM 360 RC 24201 HCPCS outpatient 1114.14 835.61 MOLINA MCAID MOLINA MCAID 929.19 83.4 999999999 869.03 1058.43 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 24201_1 CDM 360 RC 24201 HCPCS outpatient 1114.14 835.61 MOLINA MCR ADV MOLINA MCR ADV 991.58 89 999999999 869.03 1058.43 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 24201_1 CDM 360 RC 24201 HCPCS outpatient 1114.14 835.61 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 991.58 89 999999999 869.03 1058.43 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 24201_1 CDM 360 RC 24201 HCPCS outpatient 1114.14 835.61 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 991.58 89 999999999 869.03 1058.43 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 24201_1 CDM 360 RC 24201 HCPCS outpatient 1114.14 835.61 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1002.73 90 999999999 869.03 1058.43 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 24201_1 CDM 360 RC 24201 HCPCS outpatient 1114.14 835.61 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1058.43 95 999999999 869.03 1058.43 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 24201_1 CDM 360 RC 24201 HCPCS outpatient 1114.14 835.61 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1058.43 95 999999999 869.03 1058.43 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 24201_1 CDM 360 RC 24201 HCPCS outpatient 1114.14 835.61 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 991.58 89 999999999 869.03 1058.43 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 24201_1 CDM 360 RC 24201 HCPCS outpatient 1114.14 835.61 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 980.44 88 999999999 869.03 1058.43 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 24201_1 CDM 360 RC 24201 HCPCS outpatient 1114.14 835.61 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 991.58 89 999999999 869.03 1058.43 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 24201_3 CDM 360 RC 24201 HCPCS outpatient 1232 924 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1108.8 999999999 960.96 1170.4 case rate "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 24201_3 CDM 360 RC 24201 HCPCS outpatient 1232 924 AETNA MCR ADV AETNA MCR ADV 960.96 78 999999999 960.96 1170.4 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 24201_3 CDM 360 RC 24201 HCPCS outpatient 1232 924 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1078.86 87.57 999999999 960.96 1170.4 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 24201_3 CDM 360 RC 24201 HCPCS outpatient 1232 924 COORDINATED CARE MCAID COORDINATED CARE MCAID 1048.06 85.07 999999999 960.96 1170.4 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 24201_3 CDM 360 RC 24201 HCPCS outpatient 1232 924 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1048.06 85.07 999999999 960.96 1170.4 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 24201_3 CDM 360 RC 24201 HCPCS outpatient 1232 924 MOLINA MCAID MOLINA MCAID 1027.49 83.4 999999999 960.96 1170.4 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 24201_3 CDM 360 RC 24201 HCPCS outpatient 1232 924 MOLINA MCR ADV MOLINA MCR ADV 1096.48 89 999999999 960.96 1170.4 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 24201_3 CDM 360 RC 24201 HCPCS outpatient 1232 924 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1096.48 89 999999999 960.96 1170.4 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 24201_3 CDM 360 RC 24201 HCPCS outpatient 1232 924 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1096.48 89 999999999 960.96 1170.4 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 24201_3 CDM 360 RC 24201 HCPCS outpatient 1232 924 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1108.8 90 999999999 960.96 1170.4 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 24201_3 CDM 360 RC 24201 HCPCS outpatient 1232 924 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1170.4 95 999999999 960.96 1170.4 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 24201_3 CDM 360 RC 24201 HCPCS outpatient 1232 924 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1170.4 95 999999999 960.96 1170.4 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 24201_3 CDM 360 RC 24201 HCPCS outpatient 1232 924 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1096.48 89 999999999 960.96 1170.4 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 24201_3 CDM 360 RC 24201 HCPCS outpatient 1232 924 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1084.16 88 999999999 960.96 1170.4 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 24201_3 CDM 360 RC 24201 HCPCS outpatient 1232 924 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1096.48 89 999999999 960.96 1170.4 percent of total billed charges TREATMENT OF CLOSED ELBOW DISLOCATION; WITHOUT ANESTHESIA 24600_3 CDM 360 RC 24600 HCPCS outpatient 772 579 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 694.8 999999999 602.16 733.4 case rate TREATMENT OF CLOSED ELBOW DISLOCATION; WITHOUT ANESTHESIA 24600_3 CDM 360 RC 24600 HCPCS outpatient 772 579 AETNA MCR ADV AETNA MCR ADV 602.16 78 999999999 602.16 733.4 percent of total billed charges TREATMENT OF CLOSED ELBOW DISLOCATION; WITHOUT ANESTHESIA 24600_3 CDM 360 RC 24600 HCPCS outpatient 772 579 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 676.04 87.57 999999999 602.16 733.4 percent of total billed charges TREATMENT OF CLOSED ELBOW DISLOCATION; WITHOUT ANESTHESIA 24600_3 CDM 360 RC 24600 HCPCS outpatient 772 579 COORDINATED CARE MCAID COORDINATED CARE MCAID 656.74 85.07 999999999 602.16 733.4 percent of total billed charges TREATMENT OF CLOSED ELBOW DISLOCATION; WITHOUT ANESTHESIA 24600_3 CDM 360 RC 24600 HCPCS outpatient 772 579 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 656.74 85.07 999999999 602.16 733.4 percent of total billed charges TREATMENT OF CLOSED ELBOW DISLOCATION; WITHOUT ANESTHESIA 24600_3 CDM 360 RC 24600 HCPCS outpatient 772 579 MOLINA MCAID MOLINA MCAID 643.85 83.4 999999999 602.16 733.4 percent of total billed charges TREATMENT OF CLOSED ELBOW DISLOCATION; WITHOUT ANESTHESIA 24600_3 CDM 360 RC 24600 HCPCS outpatient 772 579 MOLINA MCR ADV MOLINA MCR ADV 687.08 89 999999999 602.16 733.4 percent of total billed charges TREATMENT OF CLOSED ELBOW DISLOCATION; WITHOUT ANESTHESIA 24600_3 CDM 360 RC 24600 HCPCS outpatient 772 579 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 687.08 89 999999999 602.16 733.4 percent of total billed charges TREATMENT OF CLOSED ELBOW DISLOCATION; WITHOUT ANESTHESIA 24600_3 CDM 360 RC 24600 HCPCS outpatient 772 579 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 687.08 89 999999999 602.16 733.4 percent of total billed charges TREATMENT OF CLOSED ELBOW DISLOCATION; WITHOUT ANESTHESIA 24600_3 CDM 360 RC 24600 HCPCS outpatient 772 579 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 694.8 90 999999999 602.16 733.4 percent of total billed charges TREATMENT OF CLOSED ELBOW DISLOCATION; WITHOUT ANESTHESIA 24600_3 CDM 360 RC 24600 HCPCS outpatient 772 579 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 733.4 95 999999999 602.16 733.4 percent of total billed charges TREATMENT OF CLOSED ELBOW DISLOCATION; WITHOUT ANESTHESIA 24600_3 CDM 360 RC 24600 HCPCS outpatient 772 579 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 733.4 95 999999999 602.16 733.4 percent of total billed charges TREATMENT OF CLOSED ELBOW DISLOCATION; WITHOUT ANESTHESIA 24600_3 CDM 360 RC 24600 HCPCS outpatient 772 579 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 687.08 89 999999999 602.16 733.4 percent of total billed charges TREATMENT OF CLOSED ELBOW DISLOCATION; WITHOUT ANESTHESIA 24600_3 CDM 360 RC 24600 HCPCS outpatient 772 579 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 679.36 88 999999999 602.16 733.4 percent of total billed charges TREATMENT OF CLOSED ELBOW DISLOCATION; WITHOUT ANESTHESIA 24600_3 CDM 360 RC 24600 HCPCS outpatient 772 579 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 687.08 89 999999999 602.16 733.4 percent of total billed charges "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 24640_1 CDM 360 RC 24640 HCPCS outpatient 246.21 184.66 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 221.59 999999999 192.04 233.9 case rate "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 24640_1 CDM 360 RC 24640 HCPCS outpatient 246.21 184.66 AETNA MCR ADV AETNA MCR ADV 192.04 78 999999999 192.04 233.9 percent of total billed charges "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 24640_1 CDM 360 RC 24640 HCPCS outpatient 246.21 184.66 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 215.61 87.57 999999999 192.04 233.9 percent of total billed charges "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 24640_1 CDM 360 RC 24640 HCPCS outpatient 246.21 184.66 COORDINATED CARE MCAID COORDINATED CARE MCAID 209.45 85.07 999999999 192.04 233.9 percent of total billed charges "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 24640_1 CDM 360 RC 24640 HCPCS outpatient 246.21 184.66 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 209.45 85.07 999999999 192.04 233.9 percent of total billed charges "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 24640_1 CDM 360 RC 24640 HCPCS outpatient 246.21 184.66 MOLINA MCAID MOLINA MCAID 205.34 83.4 999999999 192.04 233.9 percent of total billed charges "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 24640_1 CDM 360 RC 24640 HCPCS outpatient 246.21 184.66 MOLINA MCR ADV MOLINA MCR ADV 219.13 89 999999999 192.04 233.9 percent of total billed charges "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 24640_1 CDM 360 RC 24640 HCPCS outpatient 246.21 184.66 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 219.13 89 999999999 192.04 233.9 percent of total billed charges "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 24640_1 CDM 360 RC 24640 HCPCS outpatient 246.21 184.66 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 219.13 89 999999999 192.04 233.9 percent of total billed charges "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 24640_1 CDM 360 RC 24640 HCPCS outpatient 246.21 184.66 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 221.59 90 999999999 192.04 233.9 percent of total billed charges "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 24640_1 CDM 360 RC 24640 HCPCS outpatient 246.21 184.66 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 233.9 95 999999999 192.04 233.9 percent of total billed charges "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 24640_1 CDM 360 RC 24640 HCPCS outpatient 246.21 184.66 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 233.9 95 999999999 192.04 233.9 percent of total billed charges "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 24640_1 CDM 360 RC 24640 HCPCS outpatient 246.21 184.66 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 219.13 89 999999999 192.04 233.9 percent of total billed charges "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 24640_1 CDM 360 RC 24640 HCPCS outpatient 246.21 184.66 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 216.66 88 999999999 192.04 233.9 percent of total billed charges "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 24640_1 CDM 360 RC 24640 HCPCS outpatient 246.21 184.66 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 219.13 89 999999999 192.04 233.9 percent of total billed charges "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 24640_3 CDM 360 RC 24640 HCPCS outpatient 214 160.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 192.6 999999999 166.92 203.3 case rate "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 24640_3 CDM 360 RC 24640 HCPCS outpatient 214 160.5 AETNA MCR ADV AETNA MCR ADV 166.92 78 999999999 166.92 203.3 percent of total billed charges "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 24640_3 CDM 360 RC 24640 HCPCS outpatient 214 160.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 187.4 87.57 999999999 166.92 203.3 percent of total billed charges "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 24640_3 CDM 360 RC 24640 HCPCS outpatient 214 160.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 182.05 85.07 999999999 166.92 203.3 percent of total billed charges "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 24640_3 CDM 360 RC 24640 HCPCS outpatient 214 160.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 182.05 85.07 999999999 166.92 203.3 percent of total billed charges "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 24640_3 CDM 360 RC 24640 HCPCS outpatient 214 160.5 MOLINA MCAID MOLINA MCAID 178.48 83.4 999999999 166.92 203.3 percent of total billed charges "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 24640_3 CDM 360 RC 24640 HCPCS outpatient 214 160.5 MOLINA MCR ADV MOLINA MCR ADV 190.46 89 999999999 166.92 203.3 percent of total billed charges "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 24640_3 CDM 360 RC 24640 HCPCS outpatient 214 160.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 190.46 89 999999999 166.92 203.3 percent of total billed charges "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 24640_3 CDM 360 RC 24640 HCPCS outpatient 214 160.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 190.46 89 999999999 166.92 203.3 percent of total billed charges "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 24640_3 CDM 360 RC 24640 HCPCS outpatient 214 160.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 192.6 90 999999999 166.92 203.3 percent of total billed charges "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 24640_3 CDM 360 RC 24640 HCPCS outpatient 214 160.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 203.3 95 999999999 166.92 203.3 percent of total billed charges "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 24640_3 CDM 360 RC 24640 HCPCS outpatient 214 160.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 203.3 95 999999999 166.92 203.3 percent of total billed charges "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 24640_3 CDM 360 RC 24640 HCPCS outpatient 214 160.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 190.46 89 999999999 166.92 203.3 percent of total billed charges "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 24640_3 CDM 360 RC 24640 HCPCS outpatient 214 160.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 188.32 88 999999999 166.92 203.3 percent of total billed charges "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 24640_3 CDM 360 RC 24640 HCPCS outpatient 214 160.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 190.46 89 999999999 166.92 203.3 percent of total billed charges CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; WITHOUT MANIPULATION 24650_3 CDM 360 RC 24650 HCPCS outpatient 546 409.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 491.4 999999999 425.88 518.7 case rate CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; WITHOUT MANIPULATION 24650_3 CDM 360 RC 24650 HCPCS outpatient 546 409.5 AETNA MCR ADV AETNA MCR ADV 425.88 78 999999999 425.88 518.7 percent of total billed charges CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; WITHOUT MANIPULATION 24650_3 CDM 360 RC 24650 HCPCS outpatient 546 409.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 478.13 87.57 999999999 425.88 518.7 percent of total billed charges CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; WITHOUT MANIPULATION 24650_3 CDM 360 RC 24650 HCPCS outpatient 546 409.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 464.48 85.07 999999999 425.88 518.7 percent of total billed charges CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; WITHOUT MANIPULATION 24650_3 CDM 360 RC 24650 HCPCS outpatient 546 409.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 464.48 85.07 999999999 425.88 518.7 percent of total billed charges CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; WITHOUT MANIPULATION 24650_3 CDM 360 RC 24650 HCPCS outpatient 546 409.5 MOLINA MCAID MOLINA MCAID 455.36 83.4 999999999 425.88 518.7 percent of total billed charges CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; WITHOUT MANIPULATION 24650_3 CDM 360 RC 24650 HCPCS outpatient 546 409.5 MOLINA MCR ADV MOLINA MCR ADV 485.94 89 999999999 425.88 518.7 percent of total billed charges CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; WITHOUT MANIPULATION 24650_3 CDM 360 RC 24650 HCPCS outpatient 546 409.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 485.94 89 999999999 425.88 518.7 percent of total billed charges CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; WITHOUT MANIPULATION 24650_3 CDM 360 RC 24650 HCPCS outpatient 546 409.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 485.94 89 999999999 425.88 518.7 percent of total billed charges CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; WITHOUT MANIPULATION 24650_3 CDM 360 RC 24650 HCPCS outpatient 546 409.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 491.4 90 999999999 425.88 518.7 percent of total billed charges CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; WITHOUT MANIPULATION 24650_3 CDM 360 RC 24650 HCPCS outpatient 546 409.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 518.7 95 999999999 425.88 518.7 percent of total billed charges CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; WITHOUT MANIPULATION 24650_3 CDM 360 RC 24650 HCPCS outpatient 546 409.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 518.7 95 999999999 425.88 518.7 percent of total billed charges CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; WITHOUT MANIPULATION 24650_3 CDM 360 RC 24650 HCPCS outpatient 546 409.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 485.94 89 999999999 425.88 518.7 percent of total billed charges CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; WITHOUT MANIPULATION 24650_3 CDM 360 RC 24650 HCPCS outpatient 546 409.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 480.48 88 999999999 425.88 518.7 percent of total billed charges CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; WITHOUT MANIPULATION 24650_3 CDM 360 RC 24650 HCPCS outpatient 546 409.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 485.94 89 999999999 425.88 518.7 percent of total billed charges "EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY, FOREARM OR WRIST" 25248_3 CDM 360 RC 25248 HCPCS outpatient 854 640.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 768.6 999999999 666.12 811.3 case rate "EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY, FOREARM OR WRIST" 25248_3 CDM 360 RC 25248 HCPCS outpatient 854 640.5 AETNA MCR ADV AETNA MCR ADV 666.12 78 999999999 666.12 811.3 percent of total billed charges "EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY, FOREARM OR WRIST" 25248_3 CDM 360 RC 25248 HCPCS outpatient 854 640.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 747.85 87.57 999999999 666.12 811.3 percent of total billed charges "EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY, FOREARM OR WRIST" 25248_3 CDM 360 RC 25248 HCPCS outpatient 854 640.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 726.5 85.07 999999999 666.12 811.3 percent of total billed charges "EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY, FOREARM OR WRIST" 25248_3 CDM 360 RC 25248 HCPCS outpatient 854 640.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 726.5 85.07 999999999 666.12 811.3 percent of total billed charges "EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY, FOREARM OR WRIST" 25248_3 CDM 360 RC 25248 HCPCS outpatient 854 640.5 MOLINA MCAID MOLINA MCAID 712.24 83.4 999999999 666.12 811.3 percent of total billed charges "EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY, FOREARM OR WRIST" 25248_3 CDM 360 RC 25248 HCPCS outpatient 854 640.5 MOLINA MCR ADV MOLINA MCR ADV 760.06 89 999999999 666.12 811.3 percent of total billed charges "EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY, FOREARM OR WRIST" 25248_3 CDM 360 RC 25248 HCPCS outpatient 854 640.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 760.06 89 999999999 666.12 811.3 percent of total billed charges "EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY, FOREARM OR WRIST" 25248_3 CDM 360 RC 25248 HCPCS outpatient 854 640.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 760.06 89 999999999 666.12 811.3 percent of total billed charges "EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY, FOREARM OR WRIST" 25248_3 CDM 360 RC 25248 HCPCS outpatient 854 640.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 768.6 90 999999999 666.12 811.3 percent of total billed charges "EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY, FOREARM OR WRIST" 25248_3 CDM 360 RC 25248 HCPCS outpatient 854 640.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 811.3 95 999999999 666.12 811.3 percent of total billed charges "EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY, FOREARM OR WRIST" 25248_3 CDM 360 RC 25248 HCPCS outpatient 854 640.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 811.3 95 999999999 666.12 811.3 percent of total billed charges "EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY, FOREARM OR WRIST" 25248_3 CDM 360 RC 25248 HCPCS outpatient 854 640.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 760.06 89 999999999 666.12 811.3 percent of total billed charges "EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY, FOREARM OR WRIST" 25248_3 CDM 360 RC 25248 HCPCS outpatient 854 640.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 751.52 88 999999999 666.12 811.3 percent of total billed charges "EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY, FOREARM OR WRIST" 25248_3 CDM 360 RC 25248 HCPCS outpatient 854 640.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 760.06 89 999999999 666.12 811.3 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_1 CDM 360 RC 25605 HCPCS outpatient 1570.2 1177.65 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1413.18 999999999 1224.76 1491.69 case rate "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_1 CDM 360 RC 25605 HCPCS outpatient 1570.2 1177.65 AETNA MCR ADV AETNA MCR ADV 1224.76 78 999999999 1224.76 1491.69 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_1 CDM 360 RC 25605 HCPCS outpatient 1570.2 1177.65 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1375.02 87.57 999999999 1224.76 1491.69 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_1 CDM 360 RC 25605 HCPCS outpatient 1570.2 1177.65 COORDINATED CARE MCAID COORDINATED CARE MCAID 1335.77 85.07 999999999 1224.76 1491.69 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_1 CDM 360 RC 25605 HCPCS outpatient 1570.2 1177.65 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1335.77 85.07 999999999 1224.76 1491.69 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_1 CDM 360 RC 25605 HCPCS outpatient 1570.2 1177.65 MOLINA MCAID MOLINA MCAID 1309.55 83.4 999999999 1224.76 1491.69 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_1 CDM 360 RC 25605 HCPCS outpatient 1570.2 1177.65 MOLINA MCR ADV MOLINA MCR ADV 1397.48 89 999999999 1224.76 1491.69 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_1 CDM 360 RC 25605 HCPCS outpatient 1570.2 1177.65 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1397.48 89 999999999 1224.76 1491.69 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_1 CDM 360 RC 25605 HCPCS outpatient 1570.2 1177.65 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1397.48 89 999999999 1224.76 1491.69 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_1 CDM 360 RC 25605 HCPCS outpatient 1570.2 1177.65 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1413.18 90 999999999 1224.76 1491.69 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_1 CDM 360 RC 25605 HCPCS outpatient 1570.2 1177.65 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1491.69 95 999999999 1224.76 1491.69 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_1 CDM 360 RC 25605 HCPCS outpatient 1570.2 1177.65 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1491.69 95 999999999 1224.76 1491.69 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_1 CDM 360 RC 25605 HCPCS outpatient 1570.2 1177.65 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1397.48 89 999999999 1224.76 1491.69 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_1 CDM 360 RC 25605 HCPCS outpatient 1570.2 1177.65 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1381.78 88 999999999 1224.76 1491.69 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_1 CDM 360 RC 25605 HCPCS outpatient 1570.2 1177.65 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1397.48 89 999999999 1224.76 1491.69 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_2 CDM 360 RC 25605 HCPCS outpatient 1570.2 1177.65 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1413.18 999999999 1224.76 1491.69 case rate "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_2 CDM 360 RC 25605 HCPCS outpatient 1570.2 1177.65 AETNA MCR ADV AETNA MCR ADV 1224.76 78 999999999 1224.76 1491.69 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_2 CDM 360 RC 25605 HCPCS outpatient 1570.2 1177.65 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1375.02 87.57 999999999 1224.76 1491.69 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_2 CDM 360 RC 25605 HCPCS outpatient 1570.2 1177.65 COORDINATED CARE MCAID COORDINATED CARE MCAID 1335.77 85.07 999999999 1224.76 1491.69 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_2 CDM 360 RC 25605 HCPCS outpatient 1570.2 1177.65 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1335.77 85.07 999999999 1224.76 1491.69 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_2 CDM 360 RC 25605 HCPCS outpatient 1570.2 1177.65 MOLINA MCAID MOLINA MCAID 1309.55 83.4 999999999 1224.76 1491.69 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_2 CDM 360 RC 25605 HCPCS outpatient 1570.2 1177.65 MOLINA MCR ADV MOLINA MCR ADV 1397.48 89 999999999 1224.76 1491.69 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_2 CDM 360 RC 25605 HCPCS outpatient 1570.2 1177.65 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1397.48 89 999999999 1224.76 1491.69 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_2 CDM 360 RC 25605 HCPCS outpatient 1570.2 1177.65 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1397.48 89 999999999 1224.76 1491.69 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_2 CDM 360 RC 25605 HCPCS outpatient 1570.2 1177.65 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1413.18 90 999999999 1224.76 1491.69 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_2 CDM 360 RC 25605 HCPCS outpatient 1570.2 1177.65 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1491.69 95 999999999 1224.76 1491.69 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_2 CDM 360 RC 25605 HCPCS outpatient 1570.2 1177.65 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1491.69 95 999999999 1224.76 1491.69 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_2 CDM 360 RC 25605 HCPCS outpatient 1570.2 1177.65 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1397.48 89 999999999 1224.76 1491.69 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_2 CDM 360 RC 25605 HCPCS outpatient 1570.2 1177.65 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1381.78 88 999999999 1224.76 1491.69 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_2 CDM 360 RC 25605 HCPCS outpatient 1570.2 1177.65 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1397.48 89 999999999 1224.76 1491.69 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_3 CDM 360 RC 25605 HCPCS outpatient 1108 831 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 997.2 999999999 864.24 1052.6 case rate "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_3 CDM 360 RC 25605 HCPCS outpatient 1108 831 AETNA MCR ADV AETNA MCR ADV 864.24 78 999999999 864.24 1052.6 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_3 CDM 360 RC 25605 HCPCS outpatient 1108 831 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 970.28 87.57 999999999 864.24 1052.6 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_3 CDM 360 RC 25605 HCPCS outpatient 1108 831 COORDINATED CARE MCAID COORDINATED CARE MCAID 942.58 85.07 999999999 864.24 1052.6 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_3 CDM 360 RC 25605 HCPCS outpatient 1108 831 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 942.58 85.07 999999999 864.24 1052.6 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_3 CDM 360 RC 25605 HCPCS outpatient 1108 831 MOLINA MCAID MOLINA MCAID 924.07 83.4 999999999 864.24 1052.6 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_3 CDM 360 RC 25605 HCPCS outpatient 1108 831 MOLINA MCR ADV MOLINA MCR ADV 986.12 89 999999999 864.24 1052.6 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_3 CDM 360 RC 25605 HCPCS outpatient 1108 831 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 986.12 89 999999999 864.24 1052.6 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_3 CDM 360 RC 25605 HCPCS outpatient 1108 831 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 986.12 89 999999999 864.24 1052.6 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_3 CDM 360 RC 25605 HCPCS outpatient 1108 831 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 997.2 90 999999999 864.24 1052.6 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_3 CDM 360 RC 25605 HCPCS outpatient 1108 831 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1052.6 95 999999999 864.24 1052.6 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_3 CDM 360 RC 25605 HCPCS outpatient 1108 831 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1052.6 95 999999999 864.24 1052.6 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_3 CDM 360 RC 25605 HCPCS outpatient 1108 831 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 986.12 89 999999999 864.24 1052.6 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_3 CDM 360 RC 25605 HCPCS outpatient 1108 831 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 975.04 88 999999999 864.24 1052.6 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 25605_3 CDM 360 RC 25605 HCPCS outpatient 1108 831 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 986.12 89 999999999 864.24 1052.6 percent of total billed charges "REPAIR, EXTENSOR TENDON, FINGER, PRIMARY OR SECONDARY; WITHOUT FREE GRAFT, EACH TENDON" 26418_3 CDM 360 RC 26418 HCPCS outpatient 1310 982.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1179 999999999 1021.8 1244.5 case rate "REPAIR, EXTENSOR TENDON, FINGER, PRIMARY OR SECONDARY; WITHOUT FREE GRAFT, EACH TENDON" 26418_3 CDM 360 RC 26418 HCPCS outpatient 1310 982.5 AETNA MCR ADV AETNA MCR ADV 1021.8 78 999999999 1021.8 1244.5 percent of total billed charges "REPAIR, EXTENSOR TENDON, FINGER, PRIMARY OR SECONDARY; WITHOUT FREE GRAFT, EACH TENDON" 26418_3 CDM 360 RC 26418 HCPCS outpatient 1310 982.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1147.17 87.57 999999999 1021.8 1244.5 percent of total billed charges "REPAIR, EXTENSOR TENDON, FINGER, PRIMARY OR SECONDARY; WITHOUT FREE GRAFT, EACH TENDON" 26418_3 CDM 360 RC 26418 HCPCS outpatient 1310 982.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 1114.42 85.07 999999999 1021.8 1244.5 percent of total billed charges "REPAIR, EXTENSOR TENDON, FINGER, PRIMARY OR SECONDARY; WITHOUT FREE GRAFT, EACH TENDON" 26418_3 CDM 360 RC 26418 HCPCS outpatient 1310 982.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1114.42 85.07 999999999 1021.8 1244.5 percent of total billed charges "REPAIR, EXTENSOR TENDON, FINGER, PRIMARY OR SECONDARY; WITHOUT FREE GRAFT, EACH TENDON" 26418_3 CDM 360 RC 26418 HCPCS outpatient 1310 982.5 MOLINA MCAID MOLINA MCAID 1092.54 83.4 999999999 1021.8 1244.5 percent of total billed charges "REPAIR, EXTENSOR TENDON, FINGER, PRIMARY OR SECONDARY; WITHOUT FREE GRAFT, EACH TENDON" 26418_3 CDM 360 RC 26418 HCPCS outpatient 1310 982.5 MOLINA MCR ADV MOLINA MCR ADV 1165.9 89 999999999 1021.8 1244.5 percent of total billed charges "REPAIR, EXTENSOR TENDON, FINGER, PRIMARY OR SECONDARY; WITHOUT FREE GRAFT, EACH TENDON" 26418_3 CDM 360 RC 26418 HCPCS outpatient 1310 982.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1165.9 89 999999999 1021.8 1244.5 percent of total billed charges "REPAIR, EXTENSOR TENDON, FINGER, PRIMARY OR SECONDARY; WITHOUT FREE GRAFT, EACH TENDON" 26418_3 CDM 360 RC 26418 HCPCS outpatient 1310 982.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1165.9 89 999999999 1021.8 1244.5 percent of total billed charges "REPAIR, EXTENSOR TENDON, FINGER, PRIMARY OR SECONDARY; WITHOUT FREE GRAFT, EACH TENDON" 26418_3 CDM 360 RC 26418 HCPCS outpatient 1310 982.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1179 90 999999999 1021.8 1244.5 percent of total billed charges "REPAIR, EXTENSOR TENDON, FINGER, PRIMARY OR SECONDARY; WITHOUT FREE GRAFT, EACH TENDON" 26418_3 CDM 360 RC 26418 HCPCS outpatient 1310 982.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1244.5 95 999999999 1021.8 1244.5 percent of total billed charges "REPAIR, EXTENSOR TENDON, FINGER, PRIMARY OR SECONDARY; WITHOUT FREE GRAFT, EACH TENDON" 26418_3 CDM 360 RC 26418 HCPCS outpatient 1310 982.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1244.5 95 999999999 1021.8 1244.5 percent of total billed charges "REPAIR, EXTENSOR TENDON, FINGER, PRIMARY OR SECONDARY; WITHOUT FREE GRAFT, EACH TENDON" 26418_3 CDM 360 RC 26418 HCPCS outpatient 1310 982.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1165.9 89 999999999 1021.8 1244.5 percent of total billed charges "REPAIR, EXTENSOR TENDON, FINGER, PRIMARY OR SECONDARY; WITHOUT FREE GRAFT, EACH TENDON" 26418_3 CDM 360 RC 26418 HCPCS outpatient 1310 982.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1152.8 88 999999999 1021.8 1244.5 percent of total billed charges "REPAIR, EXTENSOR TENDON, FINGER, PRIMARY OR SECONDARY; WITHOUT FREE GRAFT, EACH TENDON" 26418_3 CDM 360 RC 26418 HCPCS outpatient 1310 982.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1165.9 89 999999999 1021.8 1244.5 percent of total billed charges "CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE; WITH MANIPULATION, EACH BONE" 26605_3 CDM 360 RC 26605 HCPCS outpatient 786 589.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 707.4 999999999 613.08 746.7 case rate "CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE; WITH MANIPULATION, EACH BONE" 26605_3 CDM 360 RC 26605 HCPCS outpatient 786 589.5 AETNA MCR ADV AETNA MCR ADV 613.08 78 999999999 613.08 746.7 percent of total billed charges "CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE; WITH MANIPULATION, EACH BONE" 26605_3 CDM 360 RC 26605 HCPCS outpatient 786 589.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 688.3 87.57 999999999 613.08 746.7 percent of total billed charges "CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE; WITH MANIPULATION, EACH BONE" 26605_3 CDM 360 RC 26605 HCPCS outpatient 786 589.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 668.65 85.07 999999999 613.08 746.7 percent of total billed charges "CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE; WITH MANIPULATION, EACH BONE" 26605_3 CDM 360 RC 26605 HCPCS outpatient 786 589.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 668.65 85.07 999999999 613.08 746.7 percent of total billed charges "CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE; WITH MANIPULATION, EACH BONE" 26605_3 CDM 360 RC 26605 HCPCS outpatient 786 589.5 MOLINA MCAID MOLINA MCAID 655.52 83.4 999999999 613.08 746.7 percent of total billed charges "CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE; WITH MANIPULATION, EACH BONE" 26605_3 CDM 360 RC 26605 HCPCS outpatient 786 589.5 MOLINA MCR ADV MOLINA MCR ADV 699.54 89 999999999 613.08 746.7 percent of total billed charges "CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE; WITH MANIPULATION, EACH BONE" 26605_3 CDM 360 RC 26605 HCPCS outpatient 786 589.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 699.54 89 999999999 613.08 746.7 percent of total billed charges "CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE; WITH MANIPULATION, EACH BONE" 26605_3 CDM 360 RC 26605 HCPCS outpatient 786 589.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 699.54 89 999999999 613.08 746.7 percent of total billed charges "CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE; WITH MANIPULATION, EACH BONE" 26605_3 CDM 360 RC 26605 HCPCS outpatient 786 589.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 707.4 90 999999999 613.08 746.7 percent of total billed charges "CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE; WITH MANIPULATION, EACH BONE" 26605_3 CDM 360 RC 26605 HCPCS outpatient 786 589.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 746.7 95 999999999 613.08 746.7 percent of total billed charges "CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE; WITH MANIPULATION, EACH BONE" 26605_3 CDM 360 RC 26605 HCPCS outpatient 786 589.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 746.7 95 999999999 613.08 746.7 percent of total billed charges "CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE; WITH MANIPULATION, EACH BONE" 26605_3 CDM 360 RC 26605 HCPCS outpatient 786 589.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 699.54 89 999999999 613.08 746.7 percent of total billed charges "CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE; WITH MANIPULATION, EACH BONE" 26605_3 CDM 360 RC 26605 HCPCS outpatient 786 589.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 691.68 88 999999999 613.08 746.7 percent of total billed charges "CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE; WITH MANIPULATION, EACH BONE" 26605_3 CDM 360 RC 26605 HCPCS outpatient 786 589.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 699.54 89 999999999 613.08 746.7 percent of total billed charges "CLOSED TREATMENT OF CARPOMETACARPAL DISLOCATION, THUMB, WITH MANIPULATION" 26641_3 CDM 360 RC 26641 HCPCS outpatient 866 649.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 779.4 999999999 675.48 822.7 case rate "CLOSED TREATMENT OF CARPOMETACARPAL DISLOCATION, THUMB, WITH MANIPULATION" 26641_3 CDM 360 RC 26641 HCPCS outpatient 866 649.5 AETNA MCR ADV AETNA MCR ADV 675.48 78 999999999 675.48 822.7 percent of total billed charges "CLOSED TREATMENT OF CARPOMETACARPAL DISLOCATION, THUMB, WITH MANIPULATION" 26641_3 CDM 360 RC 26641 HCPCS outpatient 866 649.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 758.36 87.57 999999999 675.48 822.7 percent of total billed charges "CLOSED TREATMENT OF CARPOMETACARPAL DISLOCATION, THUMB, WITH MANIPULATION" 26641_3 CDM 360 RC 26641 HCPCS outpatient 866 649.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 736.71 85.07 999999999 675.48 822.7 percent of total billed charges "CLOSED TREATMENT OF CARPOMETACARPAL DISLOCATION, THUMB, WITH MANIPULATION" 26641_3 CDM 360 RC 26641 HCPCS outpatient 866 649.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 736.71 85.07 999999999 675.48 822.7 percent of total billed charges "CLOSED TREATMENT OF CARPOMETACARPAL DISLOCATION, THUMB, WITH MANIPULATION" 26641_3 CDM 360 RC 26641 HCPCS outpatient 866 649.5 MOLINA MCAID MOLINA MCAID 722.24 83.4 999999999 675.48 822.7 percent of total billed charges "CLOSED TREATMENT OF CARPOMETACARPAL DISLOCATION, THUMB, WITH MANIPULATION" 26641_3 CDM 360 RC 26641 HCPCS outpatient 866 649.5 MOLINA MCR ADV MOLINA MCR ADV 770.74 89 999999999 675.48 822.7 percent of total billed charges "CLOSED TREATMENT OF CARPOMETACARPAL DISLOCATION, THUMB, WITH MANIPULATION" 26641_3 CDM 360 RC 26641 HCPCS outpatient 866 649.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 770.74 89 999999999 675.48 822.7 percent of total billed charges "CLOSED TREATMENT OF CARPOMETACARPAL DISLOCATION, THUMB, WITH MANIPULATION" 26641_3 CDM 360 RC 26641 HCPCS outpatient 866 649.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 770.74 89 999999999 675.48 822.7 percent of total billed charges "CLOSED TREATMENT OF CARPOMETACARPAL DISLOCATION, THUMB, WITH MANIPULATION" 26641_3 CDM 360 RC 26641 HCPCS outpatient 866 649.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 779.4 90 999999999 675.48 822.7 percent of total billed charges "CLOSED TREATMENT OF CARPOMETACARPAL DISLOCATION, THUMB, WITH MANIPULATION" 26641_3 CDM 360 RC 26641 HCPCS outpatient 866 649.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 822.7 95 999999999 675.48 822.7 percent of total billed charges "CLOSED TREATMENT OF CARPOMETACARPAL DISLOCATION, THUMB, WITH MANIPULATION" 26641_3 CDM 360 RC 26641 HCPCS outpatient 866 649.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 822.7 95 999999999 675.48 822.7 percent of total billed charges "CLOSED TREATMENT OF CARPOMETACARPAL DISLOCATION, THUMB, WITH MANIPULATION" 26641_3 CDM 360 RC 26641 HCPCS outpatient 866 649.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 770.74 89 999999999 675.48 822.7 percent of total billed charges "CLOSED TREATMENT OF CARPOMETACARPAL DISLOCATION, THUMB, WITH MANIPULATION" 26641_3 CDM 360 RC 26641 HCPCS outpatient 866 649.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 762.08 88 999999999 675.48 822.7 percent of total billed charges "CLOSED TREATMENT OF CARPOMETACARPAL DISLOCATION, THUMB, WITH MANIPULATION" 26641_3 CDM 360 RC 26641 HCPCS outpatient 866 649.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 770.74 89 999999999 675.48 822.7 percent of total billed charges "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 26725_1 CDM 360 RC 26725 HCPCS outpatient 940.44 705.33 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 846.4 999999999 733.54 893.42 case rate "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 26725_1 CDM 360 RC 26725 HCPCS outpatient 940.44 705.33 AETNA MCR ADV AETNA MCR ADV 733.54 78 999999999 733.54 893.42 percent of total billed charges "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 26725_1 CDM 360 RC 26725 HCPCS outpatient 940.44 705.33 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 823.54 87.57 999999999 733.54 893.42 percent of total billed charges "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 26725_1 CDM 360 RC 26725 HCPCS outpatient 940.44 705.33 COORDINATED CARE MCAID COORDINATED CARE MCAID 800.03 85.07 999999999 733.54 893.42 percent of total billed charges "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 26725_1 CDM 360 RC 26725 HCPCS outpatient 940.44 705.33 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 800.03 85.07 999999999 733.54 893.42 percent of total billed charges "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 26725_1 CDM 360 RC 26725 HCPCS outpatient 940.44 705.33 MOLINA MCAID MOLINA MCAID 784.33 83.4 999999999 733.54 893.42 percent of total billed charges "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 26725_1 CDM 360 RC 26725 HCPCS outpatient 940.44 705.33 MOLINA MCR ADV MOLINA MCR ADV 836.99 89 999999999 733.54 893.42 percent of total billed charges "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 26725_1 CDM 360 RC 26725 HCPCS outpatient 940.44 705.33 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 836.99 89 999999999 733.54 893.42 percent of total billed charges "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 26725_1 CDM 360 RC 26725 HCPCS outpatient 940.44 705.33 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 836.99 89 999999999 733.54 893.42 percent of total billed charges "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 26725_1 CDM 360 RC 26725 HCPCS outpatient 940.44 705.33 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 846.4 90 999999999 733.54 893.42 percent of total billed charges "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 26725_1 CDM 360 RC 26725 HCPCS outpatient 940.44 705.33 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 893.42 95 999999999 733.54 893.42 percent of total billed charges "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 26725_1 CDM 360 RC 26725 HCPCS outpatient 940.44 705.33 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 893.42 95 999999999 733.54 893.42 percent of total billed charges "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 26725_1 CDM 360 RC 26725 HCPCS outpatient 940.44 705.33 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 836.99 89 999999999 733.54 893.42 percent of total billed charges "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 26725_1 CDM 360 RC 26725 HCPCS outpatient 940.44 705.33 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 827.59 88 999999999 733.54 893.42 percent of total billed charges "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 26725_1 CDM 360 RC 26725 HCPCS outpatient 940.44 705.33 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 836.99 89 999999999 733.54 893.42 percent of total billed charges "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 26725_3 CDM 360 RC 26725 HCPCS outpatient 706 529.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 635.4 999999999 550.68 670.7 case rate "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 26725_3 CDM 360 RC 26725 HCPCS outpatient 706 529.5 AETNA MCR ADV AETNA MCR ADV 550.68 78 999999999 550.68 670.7 percent of total billed charges "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 26725_3 CDM 360 RC 26725 HCPCS outpatient 706 529.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 618.24 87.57 999999999 550.68 670.7 percent of total billed charges "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 26725_3 CDM 360 RC 26725 HCPCS outpatient 706 529.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 600.59 85.07 999999999 550.68 670.7 percent of total billed charges "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 26725_3 CDM 360 RC 26725 HCPCS outpatient 706 529.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 600.59 85.07 999999999 550.68 670.7 percent of total billed charges "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 26725_3 CDM 360 RC 26725 HCPCS outpatient 706 529.5 MOLINA MCAID MOLINA MCAID 588.8 83.4 999999999 550.68 670.7 percent of total billed charges "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 26725_3 CDM 360 RC 26725 HCPCS outpatient 706 529.5 MOLINA MCR ADV MOLINA MCR ADV 628.34 89 999999999 550.68 670.7 percent of total billed charges "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 26725_3 CDM 360 RC 26725 HCPCS outpatient 706 529.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 628.34 89 999999999 550.68 670.7 percent of total billed charges "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 26725_3 CDM 360 RC 26725 HCPCS outpatient 706 529.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 628.34 89 999999999 550.68 670.7 percent of total billed charges "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 26725_3 CDM 360 RC 26725 HCPCS outpatient 706 529.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 635.4 90 999999999 550.68 670.7 percent of total billed charges "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 26725_3 CDM 360 RC 26725 HCPCS outpatient 706 529.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 670.7 95 999999999 550.68 670.7 percent of total billed charges "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 26725_3 CDM 360 RC 26725 HCPCS outpatient 706 529.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 670.7 95 999999999 550.68 670.7 percent of total billed charges "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 26725_3 CDM 360 RC 26725 HCPCS outpatient 706 529.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 628.34 89 999999999 550.68 670.7 percent of total billed charges "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 26725_3 CDM 360 RC 26725 HCPCS outpatient 706 529.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 621.28 88 999999999 550.68 670.7 percent of total billed charges "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 26725_3 CDM 360 RC 26725 HCPCS outpatient 706 529.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 628.34 89 999999999 550.68 670.7 percent of total billed charges "CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, WITH MANIPULATION; WITHOUT ANESTHESIA" 26770_1 CDM 360 RC 26770 HCPCS outpatient 801.3 600.98 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 721.17 999999999 625.01 761.24 case rate "CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, WITH MANIPULATION; WITHOUT ANESTHESIA" 26770_1 CDM 360 RC 26770 HCPCS outpatient 801.3 600.98 AETNA MCR ADV AETNA MCR ADV 625.01 78 999999999 625.01 761.24 percent of total billed charges "CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, WITH MANIPULATION; WITHOUT ANESTHESIA" 26770_1 CDM 360 RC 26770 HCPCS outpatient 801.3 600.98 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 701.7 87.57 999999999 625.01 761.24 percent of total billed charges "CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, WITH MANIPULATION; WITHOUT ANESTHESIA" 26770_1 CDM 360 RC 26770 HCPCS outpatient 801.3 600.98 COORDINATED CARE MCAID COORDINATED CARE MCAID 681.67 85.07 999999999 625.01 761.24 percent of total billed charges "CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, WITH MANIPULATION; WITHOUT ANESTHESIA" 26770_1 CDM 360 RC 26770 HCPCS outpatient 801.3 600.98 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 681.67 85.07 999999999 625.01 761.24 percent of total billed charges "CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, WITH MANIPULATION; WITHOUT ANESTHESIA" 26770_1 CDM 360 RC 26770 HCPCS outpatient 801.3 600.98 MOLINA MCAID MOLINA MCAID 668.28 83.4 999999999 625.01 761.24 percent of total billed charges "CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, WITH MANIPULATION; WITHOUT ANESTHESIA" 26770_1 CDM 360 RC 26770 HCPCS outpatient 801.3 600.98 MOLINA MCR ADV MOLINA MCR ADV 713.16 89 999999999 625.01 761.24 percent of total billed charges "CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, WITH MANIPULATION; WITHOUT ANESTHESIA" 26770_1 CDM 360 RC 26770 HCPCS outpatient 801.3 600.98 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 713.16 89 999999999 625.01 761.24 percent of total billed charges "CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, WITH MANIPULATION; WITHOUT ANESTHESIA" 26770_1 CDM 360 RC 26770 HCPCS outpatient 801.3 600.98 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 713.16 89 999999999 625.01 761.24 percent of total billed charges "CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, WITH MANIPULATION; WITHOUT ANESTHESIA" 26770_1 CDM 360 RC 26770 HCPCS outpatient 801.3 600.98 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 721.17 90 999999999 625.01 761.24 percent of total billed charges "CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, WITH MANIPULATION; WITHOUT ANESTHESIA" 26770_1 CDM 360 RC 26770 HCPCS outpatient 801.3 600.98 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 761.24 95 999999999 625.01 761.24 percent of total billed charges "CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, WITH MANIPULATION; WITHOUT ANESTHESIA" 26770_1 CDM 360 RC 26770 HCPCS outpatient 801.3 600.98 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 761.24 95 999999999 625.01 761.24 percent of total billed charges "CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, WITH MANIPULATION; WITHOUT ANESTHESIA" 26770_1 CDM 360 RC 26770 HCPCS outpatient 801.3 600.98 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 713.16 89 999999999 625.01 761.24 percent of total billed charges "CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, WITH MANIPULATION; WITHOUT ANESTHESIA" 26770_1 CDM 360 RC 26770 HCPCS outpatient 801.3 600.98 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 705.14 88 999999999 625.01 761.24 percent of total billed charges "CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, WITH MANIPULATION; WITHOUT ANESTHESIA" 26770_1 CDM 360 RC 26770 HCPCS outpatient 801.3 600.98 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 713.16 89 999999999 625.01 761.24 percent of total billed charges "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_1 CDM 490 RC 27096 HCPCS outpatient 1575 1181.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1417.5 999999999 1228.5 1496.25 case rate "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_1 CDM 490 RC 27096 HCPCS outpatient 1575 1181.25 AETNA MCR ADV AETNA MCR ADV 1228.5 78 999999999 1228.5 1496.25 percent of total billed charges "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_1 CDM 490 RC 27096 HCPCS outpatient 1575 1181.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1379.23 87.57 999999999 1228.5 1496.25 percent of total billed charges "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_1 CDM 490 RC 27096 HCPCS outpatient 1575 1181.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 1339.85 85.07 999999999 1228.5 1496.25 percent of total billed charges "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_1 CDM 490 RC 27096 HCPCS outpatient 1575 1181.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1339.85 85.07 999999999 1228.5 1496.25 percent of total billed charges "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_1 CDM 490 RC 27096 HCPCS outpatient 1575 1181.25 MOLINA MCAID MOLINA MCAID 1313.55 83.4 999999999 1228.5 1496.25 percent of total billed charges "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_1 CDM 490 RC 27096 HCPCS outpatient 1575 1181.25 MOLINA MCR ADV MOLINA MCR ADV 1401.75 89 999999999 1228.5 1496.25 percent of total billed charges "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_1 CDM 490 RC 27096 HCPCS outpatient 1575 1181.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1401.75 89 999999999 1228.5 1496.25 percent of total billed charges "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_1 CDM 490 RC 27096 HCPCS outpatient 1575 1181.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1401.75 89 999999999 1228.5 1496.25 percent of total billed charges "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_1 CDM 490 RC 27096 HCPCS outpatient 1575 1181.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1417.5 90 999999999 1228.5 1496.25 percent of total billed charges "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_1 CDM 490 RC 27096 HCPCS outpatient 1575 1181.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1496.25 95 999999999 1228.5 1496.25 percent of total billed charges "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_1 CDM 490 RC 27096 HCPCS outpatient 1575 1181.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1496.25 95 999999999 1228.5 1496.25 percent of total billed charges "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_1 CDM 490 RC 27096 HCPCS outpatient 1575 1181.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1401.75 89 999999999 1228.5 1496.25 percent of total billed charges "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_1 CDM 490 RC 27096 HCPCS outpatient 1575 1181.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1386 88 999999999 1228.5 1496.25 percent of total billed charges "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_1 CDM 490 RC 27096 HCPCS outpatient 1575 1181.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1401.75 89 999999999 1228.5 1496.25 percent of total billed charges "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_50 CDM 490 RC 27096 HCPCS inpatient 1350 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 999999999 "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_50 CDM 490 RC 27096 HCPCS inpatient 1350 AETNA MCR ADV AETNA MCR ADV 50 999999999 "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_50 CDM 490 RC 27096 HCPCS inpatient 1350 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 999999999 "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_50 CDM 490 RC 27096 HCPCS inpatient 1350 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 999999999 "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_50 CDM 490 RC 27096 HCPCS inpatient 1350 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 999999999 "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_50 CDM 490 RC 27096 HCPCS inpatient 1350 MOLINA MCAID MOLINA MCAID 50 999999999 "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_50 CDM 490 RC 27096 HCPCS inpatient 1350 MOLINA MCR ADV MOLINA MCR ADV 50 999999999 "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_50 CDM 490 RC 27096 HCPCS inpatient 1350 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 999999999 "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_50 CDM 490 RC 27096 HCPCS inpatient 1350 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 999999999 "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_50 CDM 490 RC 27096 HCPCS inpatient 1350 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 999999999 "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_50 CDM 490 RC 27096 HCPCS inpatient 1350 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 999999999 "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_50 CDM 490 RC 27096 HCPCS inpatient 1350 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 999999999 "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_50 CDM 490 RC 27096 HCPCS inpatient 1350 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 999999999 "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_50 CDM 490 RC 27096 HCPCS inpatient 1350 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 999999999 "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_50 CDM 490 RC 27096 HCPCS inpatient 1350 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 999999999 "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_50_1 CDM 490 RC 27096 HCPCS outpatient 1350 1012.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 1215 999999999 1053 1282.5 case rate "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_50_1 CDM 490 RC 27096 HCPCS outpatient 1350 1012.5 AETNA MCR ADV AETNA MCR ADV 50 1053 78 999999999 1053 1282.5 percent of total billed charges "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_50_1 CDM 490 RC 27096 HCPCS outpatient 1350 1012.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 1182.2 87.57 999999999 1053 1282.5 percent of total billed charges "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_50_1 CDM 490 RC 27096 HCPCS outpatient 1350 1012.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 1148.45 85.07 999999999 1053 1282.5 percent of total billed charges "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_50_1 CDM 490 RC 27096 HCPCS outpatient 1350 1012.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 1148.45 85.07 999999999 1053 1282.5 percent of total billed charges "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_50_1 CDM 490 RC 27096 HCPCS outpatient 1350 1012.5 MOLINA MCAID MOLINA MCAID 50 1125.9 83.4 999999999 1053 1282.5 percent of total billed charges "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_50_1 CDM 490 RC 27096 HCPCS outpatient 1350 1012.5 MOLINA MCR ADV MOLINA MCR ADV 50 1201.5 89 999999999 1053 1282.5 percent of total billed charges "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_50_1 CDM 490 RC 27096 HCPCS outpatient 1350 1012.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 1201.5 89 999999999 1053 1282.5 percent of total billed charges "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_50_1 CDM 490 RC 27096 HCPCS outpatient 1350 1012.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 1201.5 89 999999999 1053 1282.5 percent of total billed charges "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_50_1 CDM 490 RC 27096 HCPCS outpatient 1350 1012.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 1215 90 999999999 1053 1282.5 percent of total billed charges "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_50_1 CDM 490 RC 27096 HCPCS outpatient 1350 1012.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 1282.5 95 999999999 1053 1282.5 percent of total billed charges "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_50_1 CDM 490 RC 27096 HCPCS outpatient 1350 1012.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 1282.5 95 999999999 1053 1282.5 percent of total billed charges "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_50_1 CDM 490 RC 27096 HCPCS outpatient 1350 1012.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 1201.5 89 999999999 1053 1282.5 percent of total billed charges "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_50_1 CDM 490 RC 27096 HCPCS outpatient 1350 1012.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 1188 88 999999999 1053 1282.5 percent of total billed charges "INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED" 27096_50_1 CDM 490 RC 27096 HCPCS outpatient 1350 1012.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 1201.5 89 999999999 1053 1282.5 percent of total billed charges "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 27252_1 CDM 360 RC 27252 HCPCS outpatient 2287.98 1715.99 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 2059.18 999999999 1784.62 2173.58 case rate "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 27252_1 CDM 360 RC 27252 HCPCS outpatient 2287.98 1715.99 AETNA MCR ADV AETNA MCR ADV 1784.62 78 999999999 1784.62 2173.58 percent of total billed charges "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 27252_1 CDM 360 RC 27252 HCPCS outpatient 2287.98 1715.99 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 2003.58 87.57 999999999 1784.62 2173.58 percent of total billed charges "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 27252_1 CDM 360 RC 27252 HCPCS outpatient 2287.98 1715.99 COORDINATED CARE MCAID COORDINATED CARE MCAID 1946.38 85.07 999999999 1784.62 2173.58 percent of total billed charges "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 27252_1 CDM 360 RC 27252 HCPCS outpatient 2287.98 1715.99 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1946.38 85.07 999999999 1784.62 2173.58 percent of total billed charges "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 27252_1 CDM 360 RC 27252 HCPCS outpatient 2287.98 1715.99 MOLINA MCAID MOLINA MCAID 1908.18 83.4 999999999 1784.62 2173.58 percent of total billed charges "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 27252_1 CDM 360 RC 27252 HCPCS outpatient 2287.98 1715.99 MOLINA MCR ADV MOLINA MCR ADV 2036.3 89 999999999 1784.62 2173.58 percent of total billed charges "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 27252_1 CDM 360 RC 27252 HCPCS outpatient 2287.98 1715.99 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 2036.3 89 999999999 1784.62 2173.58 percent of total billed charges "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 27252_1 CDM 360 RC 27252 HCPCS outpatient 2287.98 1715.99 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 2036.3 89 999999999 1784.62 2173.58 percent of total billed charges "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 27252_1 CDM 360 RC 27252 HCPCS outpatient 2287.98 1715.99 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 2059.18 90 999999999 1784.62 2173.58 percent of total billed charges "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 27252_1 CDM 360 RC 27252 HCPCS outpatient 2287.98 1715.99 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 2173.58 95 999999999 1784.62 2173.58 percent of total billed charges "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 27252_1 CDM 360 RC 27252 HCPCS outpatient 2287.98 1715.99 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 2173.58 95 999999999 1784.62 2173.58 percent of total billed charges "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 27252_1 CDM 360 RC 27252 HCPCS outpatient 2287.98 1715.99 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 2036.3 89 999999999 1784.62 2173.58 percent of total billed charges "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 27252_1 CDM 360 RC 27252 HCPCS outpatient 2287.98 1715.99 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 2013.42 88 999999999 1784.62 2173.58 percent of total billed charges "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 27252_1 CDM 360 RC 27252 HCPCS outpatient 2287.98 1715.99 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 2036.3 89 999999999 1784.62 2173.58 percent of total billed charges "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 27252_3 CDM 360 RC 27252 HCPCS outpatient 1524 1143 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1371.6 999999999 1188.72 1447.8 case rate "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 27252_3 CDM 360 RC 27252 HCPCS outpatient 1524 1143 AETNA MCR ADV AETNA MCR ADV 1188.72 78 999999999 1188.72 1447.8 percent of total billed charges "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 27252_3 CDM 360 RC 27252 HCPCS outpatient 1524 1143 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1334.57 87.57 999999999 1188.72 1447.8 percent of total billed charges "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 27252_3 CDM 360 RC 27252 HCPCS outpatient 1524 1143 COORDINATED CARE MCAID COORDINATED CARE MCAID 1296.47 85.07 999999999 1188.72 1447.8 percent of total billed charges "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 27252_3 CDM 360 RC 27252 HCPCS outpatient 1524 1143 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1296.47 85.07 999999999 1188.72 1447.8 percent of total billed charges "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 27252_3 CDM 360 RC 27252 HCPCS outpatient 1524 1143 MOLINA MCAID MOLINA MCAID 1271.02 83.4 999999999 1188.72 1447.8 percent of total billed charges "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 27252_3 CDM 360 RC 27252 HCPCS outpatient 1524 1143 MOLINA MCR ADV MOLINA MCR ADV 1356.36 89 999999999 1188.72 1447.8 percent of total billed charges "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 27252_3 CDM 360 RC 27252 HCPCS outpatient 1524 1143 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1356.36 89 999999999 1188.72 1447.8 percent of total billed charges "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 27252_3 CDM 360 RC 27252 HCPCS outpatient 1524 1143 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1356.36 89 999999999 1188.72 1447.8 percent of total billed charges "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 27252_3 CDM 360 RC 27252 HCPCS outpatient 1524 1143 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1371.6 90 999999999 1188.72 1447.8 percent of total billed charges "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 27252_3 CDM 360 RC 27252 HCPCS outpatient 1524 1143 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1447.8 95 999999999 1188.72 1447.8 percent of total billed charges "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 27252_3 CDM 360 RC 27252 HCPCS outpatient 1524 1143 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1447.8 95 999999999 1188.72 1447.8 percent of total billed charges "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 27252_3 CDM 360 RC 27252 HCPCS outpatient 1524 1143 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1356.36 89 999999999 1188.72 1447.8 percent of total billed charges "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 27252_3 CDM 360 RC 27252 HCPCS outpatient 1524 1143 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1341.12 88 999999999 1188.72 1447.8 percent of total billed charges "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 27252_3 CDM 360 RC 27252 HCPCS outpatient 1524 1143 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1356.36 89 999999999 1188.72 1447.8 percent of total billed charges "CERVICAL, FLEXIBLE, NON-ADJUSTABLE, PREFABRICATED, OFF-THE-SHELF (FOAM COLLAR)" 274L012000_1 CDM 274 RC L0120 HCPCS outpatient 42 31.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 37.8 90 999999999 32.76 39.9 percent of total billed charges "CERVICAL, FLEXIBLE, NON-ADJUSTABLE, PREFABRICATED, OFF-THE-SHELF (FOAM COLLAR)" 274L012000_1 CDM 274 RC L0120 HCPCS outpatient 42 31.5 AETNA MCR ADV AETNA MCR ADV 32.76 78 999999999 32.76 39.9 percent of total billed charges "CERVICAL, FLEXIBLE, NON-ADJUSTABLE, PREFABRICATED, OFF-THE-SHELF (FOAM COLLAR)" 274L012000_1 CDM 274 RC L0120 HCPCS outpatient 42 31.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 36.78 87.57 999999999 32.76 39.9 percent of total billed charges "CERVICAL, FLEXIBLE, NON-ADJUSTABLE, PREFABRICATED, OFF-THE-SHELF (FOAM COLLAR)" 274L012000_1 CDM 274 RC L0120 HCPCS outpatient 42 31.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 35.73 85.07 999999999 32.76 39.9 percent of total billed charges "CERVICAL, FLEXIBLE, NON-ADJUSTABLE, PREFABRICATED, OFF-THE-SHELF (FOAM COLLAR)" 274L012000_1 CDM 274 RC L0120 HCPCS outpatient 42 31.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 35.73 85.07 999999999 32.76 39.9 percent of total billed charges "CERVICAL, FLEXIBLE, NON-ADJUSTABLE, PREFABRICATED, OFF-THE-SHELF (FOAM COLLAR)" 274L012000_1 CDM 274 RC L0120 HCPCS outpatient 42 31.5 MOLINA MCAID MOLINA MCAID 35.03 83.4 999999999 32.76 39.9 percent of total billed charges "CERVICAL, FLEXIBLE, NON-ADJUSTABLE, PREFABRICATED, OFF-THE-SHELF (FOAM COLLAR)" 274L012000_1 CDM 274 RC L0120 HCPCS outpatient 42 31.5 MOLINA MCR ADV MOLINA MCR ADV 37.38 89 999999999 32.76 39.9 percent of total billed charges "CERVICAL, FLEXIBLE, NON-ADJUSTABLE, PREFABRICATED, OFF-THE-SHELF (FOAM COLLAR)" 274L012000_1 CDM 274 RC L0120 HCPCS outpatient 42 31.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 37.38 89 999999999 32.76 39.9 percent of total billed charges "CERVICAL, FLEXIBLE, NON-ADJUSTABLE, PREFABRICATED, OFF-THE-SHELF (FOAM COLLAR)" 274L012000_1 CDM 274 RC L0120 HCPCS outpatient 42 31.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 37.38 89 999999999 32.76 39.9 percent of total billed charges "CERVICAL, FLEXIBLE, NON-ADJUSTABLE, PREFABRICATED, OFF-THE-SHELF (FOAM COLLAR)" 274L012000_1 CDM 274 RC L0120 HCPCS outpatient 42 31.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 37.8 90 999999999 32.76 39.9 percent of total billed charges "CERVICAL, FLEXIBLE, NON-ADJUSTABLE, PREFABRICATED, OFF-THE-SHELF (FOAM COLLAR)" 274L012000_1 CDM 274 RC L0120 HCPCS outpatient 42 31.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 39.9 95 999999999 32.76 39.9 percent of total billed charges "CERVICAL, FLEXIBLE, NON-ADJUSTABLE, PREFABRICATED, OFF-THE-SHELF (FOAM COLLAR)" 274L012000_1 CDM 274 RC L0120 HCPCS outpatient 42 31.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 39.9 95 999999999 32.76 39.9 percent of total billed charges "CERVICAL, FLEXIBLE, NON-ADJUSTABLE, PREFABRICATED, OFF-THE-SHELF (FOAM COLLAR)" 274L012000_1 CDM 274 RC L0120 HCPCS outpatient 42 31.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 37.38 89 999999999 32.76 39.9 percent of total billed charges "CERVICAL, FLEXIBLE, NON-ADJUSTABLE, PREFABRICATED, OFF-THE-SHELF (FOAM COLLAR)" 274L012000_1 CDM 274 RC L0120 HCPCS outpatient 42 31.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 36.96 88 999999999 32.76 39.9 percent of total billed charges "CERVICAL, FLEXIBLE, NON-ADJUSTABLE, PREFABRICATED, OFF-THE-SHELF (FOAM COLLAR)" 274L012000_1 CDM 274 RC L0120 HCPCS outpatient 42 31.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 37.38 89 999999999 32.76 39.9 percent of total billed charges "SHOULDER ORTHOSIS, FIGURE OF EIGHT DESIGN ABDUCTION RESTRAINER, PREFABRICATED, OFF-THE-SHELF" 274L365001_1 CDM 274 RC L3650 HCPCS outpatient 125 93.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 112.5 90 999999999 97.5 118.75 percent of total billed charges "SHOULDER ORTHOSIS, FIGURE OF EIGHT DESIGN ABDUCTION RESTRAINER, PREFABRICATED, OFF-THE-SHELF" 274L365001_1 CDM 274 RC L3650 HCPCS outpatient 125 93.75 AETNA MCR ADV AETNA MCR ADV 97.5 78 999999999 97.5 118.75 percent of total billed charges "SHOULDER ORTHOSIS, FIGURE OF EIGHT DESIGN ABDUCTION RESTRAINER, PREFABRICATED, OFF-THE-SHELF" 274L365001_1 CDM 274 RC L3650 HCPCS outpatient 125 93.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 109.46 87.57 999999999 97.5 118.75 percent of total billed charges "SHOULDER ORTHOSIS, FIGURE OF EIGHT DESIGN ABDUCTION RESTRAINER, PREFABRICATED, OFF-THE-SHELF" 274L365001_1 CDM 274 RC L3650 HCPCS outpatient 125 93.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 106.34 85.07 999999999 97.5 118.75 percent of total billed charges "SHOULDER ORTHOSIS, FIGURE OF EIGHT DESIGN ABDUCTION RESTRAINER, PREFABRICATED, OFF-THE-SHELF" 274L365001_1 CDM 274 RC L3650 HCPCS outpatient 125 93.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 106.34 85.07 999999999 97.5 118.75 percent of total billed charges "SHOULDER ORTHOSIS, FIGURE OF EIGHT DESIGN ABDUCTION RESTRAINER, PREFABRICATED, OFF-THE-SHELF" 274L365001_1 CDM 274 RC L3650 HCPCS outpatient 125 93.75 MOLINA MCAID MOLINA MCAID 104.25 83.4 999999999 97.5 118.75 percent of total billed charges "SHOULDER ORTHOSIS, FIGURE OF EIGHT DESIGN ABDUCTION RESTRAINER, PREFABRICATED, OFF-THE-SHELF" 274L365001_1 CDM 274 RC L3650 HCPCS outpatient 125 93.75 MOLINA MCR ADV MOLINA MCR ADV 111.25 89 999999999 97.5 118.75 percent of total billed charges "SHOULDER ORTHOSIS, FIGURE OF EIGHT DESIGN ABDUCTION RESTRAINER, PREFABRICATED, OFF-THE-SHELF" 274L365001_1 CDM 274 RC L3650 HCPCS outpatient 125 93.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 111.25 89 999999999 97.5 118.75 percent of total billed charges "SHOULDER ORTHOSIS, FIGURE OF EIGHT DESIGN ABDUCTION RESTRAINER, PREFABRICATED, OFF-THE-SHELF" 274L365001_1 CDM 274 RC L3650 HCPCS outpatient 125 93.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 111.25 89 999999999 97.5 118.75 percent of total billed charges "SHOULDER ORTHOSIS, FIGURE OF EIGHT DESIGN ABDUCTION RESTRAINER, PREFABRICATED, OFF-THE-SHELF" 274L365001_1 CDM 274 RC L3650 HCPCS outpatient 125 93.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 112.5 90 999999999 97.5 118.75 percent of total billed charges "SHOULDER ORTHOSIS, FIGURE OF EIGHT DESIGN ABDUCTION RESTRAINER, PREFABRICATED, OFF-THE-SHELF" 274L365001_1 CDM 274 RC L3650 HCPCS outpatient 125 93.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 118.75 95 999999999 97.5 118.75 percent of total billed charges "SHOULDER ORTHOSIS, FIGURE OF EIGHT DESIGN ABDUCTION RESTRAINER, PREFABRICATED, OFF-THE-SHELF" 274L365001_1 CDM 274 RC L3650 HCPCS outpatient 125 93.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 118.75 95 999999999 97.5 118.75 percent of total billed charges "SHOULDER ORTHOSIS, FIGURE OF EIGHT DESIGN ABDUCTION RESTRAINER, PREFABRICATED, OFF-THE-SHELF" 274L365001_1 CDM 274 RC L3650 HCPCS outpatient 125 93.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 111.25 89 999999999 97.5 118.75 percent of total billed charges "SHOULDER ORTHOSIS, FIGURE OF EIGHT DESIGN ABDUCTION RESTRAINER, PREFABRICATED, OFF-THE-SHELF" 274L365001_1 CDM 274 RC L3650 HCPCS outpatient 125 93.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 110 88 999999999 97.5 118.75 percent of total billed charges "SHOULDER ORTHOSIS, FIGURE OF EIGHT DESIGN ABDUCTION RESTRAINER, PREFABRICATED, OFF-THE-SHELF" 274L365001_1 CDM 274 RC L3650 HCPCS outpatient 125 93.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 111.25 89 999999999 97.5 118.75 percent of total billed charges CLOSED TREATMENT OF PATELLAR DISLOCATION; WITHOUT ANESTHESIA 27560_3 CDM 360 RC 27560 HCPCS outpatient 760 570 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 684 999999999 592.8 722 case rate CLOSED TREATMENT OF PATELLAR DISLOCATION; WITHOUT ANESTHESIA 27560_3 CDM 360 RC 27560 HCPCS outpatient 760 570 AETNA MCR ADV AETNA MCR ADV 592.8 78 999999999 592.8 722 percent of total billed charges CLOSED TREATMENT OF PATELLAR DISLOCATION; WITHOUT ANESTHESIA 27560_3 CDM 360 RC 27560 HCPCS outpatient 760 570 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 665.53 87.57 999999999 592.8 722 percent of total billed charges CLOSED TREATMENT OF PATELLAR DISLOCATION; WITHOUT ANESTHESIA 27560_3 CDM 360 RC 27560 HCPCS outpatient 760 570 COORDINATED CARE MCAID COORDINATED CARE MCAID 646.53 85.07 999999999 592.8 722 percent of total billed charges CLOSED TREATMENT OF PATELLAR DISLOCATION; WITHOUT ANESTHESIA 27560_3 CDM 360 RC 27560 HCPCS outpatient 760 570 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 646.53 85.07 999999999 592.8 722 percent of total billed charges CLOSED TREATMENT OF PATELLAR DISLOCATION; WITHOUT ANESTHESIA 27560_3 CDM 360 RC 27560 HCPCS outpatient 760 570 MOLINA MCAID MOLINA MCAID 633.84 83.4 999999999 592.8 722 percent of total billed charges CLOSED TREATMENT OF PATELLAR DISLOCATION; WITHOUT ANESTHESIA 27560_3 CDM 360 RC 27560 HCPCS outpatient 760 570 MOLINA MCR ADV MOLINA MCR ADV 676.4 89 999999999 592.8 722 percent of total billed charges CLOSED TREATMENT OF PATELLAR DISLOCATION; WITHOUT ANESTHESIA 27560_3 CDM 360 RC 27560 HCPCS outpatient 760 570 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 676.4 89 999999999 592.8 722 percent of total billed charges CLOSED TREATMENT OF PATELLAR DISLOCATION; WITHOUT ANESTHESIA 27560_3 CDM 360 RC 27560 HCPCS outpatient 760 570 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 676.4 89 999999999 592.8 722 percent of total billed charges CLOSED TREATMENT OF PATELLAR DISLOCATION; WITHOUT ANESTHESIA 27560_3 CDM 360 RC 27560 HCPCS outpatient 760 570 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 684 90 999999999 592.8 722 percent of total billed charges CLOSED TREATMENT OF PATELLAR DISLOCATION; WITHOUT ANESTHESIA 27560_3 CDM 360 RC 27560 HCPCS outpatient 760 570 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 722 95 999999999 592.8 722 percent of total billed charges CLOSED TREATMENT OF PATELLAR DISLOCATION; WITHOUT ANESTHESIA 27560_3 CDM 360 RC 27560 HCPCS outpatient 760 570 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 722 95 999999999 592.8 722 percent of total billed charges CLOSED TREATMENT OF PATELLAR DISLOCATION; WITHOUT ANESTHESIA 27560_3 CDM 360 RC 27560 HCPCS outpatient 760 570 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 676.4 89 999999999 592.8 722 percent of total billed charges CLOSED TREATMENT OF PATELLAR DISLOCATION; WITHOUT ANESTHESIA 27560_3 CDM 360 RC 27560 HCPCS outpatient 760 570 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 668.8 88 999999999 592.8 722 percent of total billed charges CLOSED TREATMENT OF PATELLAR DISLOCATION; WITHOUT ANESTHESIA 27560_3 CDM 360 RC 27560 HCPCS outpatient 760 570 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 676.4 89 999999999 592.8 722 percent of total billed charges CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE); WITHOUT MANIPULATION 27750_3 CDM 360 RC 27750 HCPCS outpatient 720 540 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 648 999999999 561.6 684 case rate CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE); WITHOUT MANIPULATION 27750_3 CDM 360 RC 27750 HCPCS outpatient 720 540 AETNA MCR ADV AETNA MCR ADV 561.6 78 999999999 561.6 684 percent of total billed charges CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE); WITHOUT MANIPULATION 27750_3 CDM 360 RC 27750 HCPCS outpatient 720 540 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 630.5 87.57 999999999 561.6 684 percent of total billed charges CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE); WITHOUT MANIPULATION 27750_3 CDM 360 RC 27750 HCPCS outpatient 720 540 COORDINATED CARE MCAID COORDINATED CARE MCAID 612.5 85.07 999999999 561.6 684 percent of total billed charges CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE); WITHOUT MANIPULATION 27750_3 CDM 360 RC 27750 HCPCS outpatient 720 540 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 612.5 85.07 999999999 561.6 684 percent of total billed charges CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE); WITHOUT MANIPULATION 27750_3 CDM 360 RC 27750 HCPCS outpatient 720 540 MOLINA MCAID MOLINA MCAID 600.48 83.4 999999999 561.6 684 percent of total billed charges CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE); WITHOUT MANIPULATION 27750_3 CDM 360 RC 27750 HCPCS outpatient 720 540 MOLINA MCR ADV MOLINA MCR ADV 640.8 89 999999999 561.6 684 percent of total billed charges CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE); WITHOUT MANIPULATION 27750_3 CDM 360 RC 27750 HCPCS outpatient 720 540 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 640.8 89 999999999 561.6 684 percent of total billed charges CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE); WITHOUT MANIPULATION 27750_3 CDM 360 RC 27750 HCPCS outpatient 720 540 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 640.8 89 999999999 561.6 684 percent of total billed charges CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE); WITHOUT MANIPULATION 27750_3 CDM 360 RC 27750 HCPCS outpatient 720 540 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 648 90 999999999 561.6 684 percent of total billed charges CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE); WITHOUT MANIPULATION 27750_3 CDM 360 RC 27750 HCPCS outpatient 720 540 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 684 95 999999999 561.6 684 percent of total billed charges CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE); WITHOUT MANIPULATION 27750_3 CDM 360 RC 27750 HCPCS outpatient 720 540 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 684 95 999999999 561.6 684 percent of total billed charges CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE); WITHOUT MANIPULATION 27750_3 CDM 360 RC 27750 HCPCS outpatient 720 540 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 640.8 89 999999999 561.6 684 percent of total billed charges CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE); WITHOUT MANIPULATION 27750_3 CDM 360 RC 27750 HCPCS outpatient 720 540 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 633.6 88 999999999 561.6 684 percent of total billed charges CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE); WITHOUT MANIPULATION 27750_3 CDM 360 RC 27750 HCPCS outpatient 720 540 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 640.8 89 999999999 561.6 684 percent of total billed charges "CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG, LATERAL AND MEDIAL MALLEOLI, OR LATERAL AND POSTERIOR MALLEOLI OR MEDIAL AND POSTERIOR MALLEOLI); WITH MANIPULATION" 27810_3 CDM 360 RC 27810 HCPCS outpatient 968 726 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 871.2 999999999 755.04 919.6 case rate "CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG, LATERAL AND MEDIAL MALLEOLI, OR LATERAL AND POSTERIOR MALLEOLI OR MEDIAL AND POSTERIOR MALLEOLI); WITH MANIPULATION" 27810_3 CDM 360 RC 27810 HCPCS outpatient 968 726 AETNA MCR ADV AETNA MCR ADV 755.04 78 999999999 755.04 919.6 percent of total billed charges "CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG, LATERAL AND MEDIAL MALLEOLI, OR LATERAL AND POSTERIOR MALLEOLI OR MEDIAL AND POSTERIOR MALLEOLI); WITH MANIPULATION" 27810_3 CDM 360 RC 27810 HCPCS outpatient 968 726 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 847.68 87.57 999999999 755.04 919.6 percent of total billed charges "CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG, LATERAL AND MEDIAL MALLEOLI, OR LATERAL AND POSTERIOR MALLEOLI OR MEDIAL AND POSTERIOR MALLEOLI); WITH MANIPULATION" 27810_3 CDM 360 RC 27810 HCPCS outpatient 968 726 COORDINATED CARE MCAID COORDINATED CARE MCAID 823.48 85.07 999999999 755.04 919.6 percent of total billed charges "CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG, LATERAL AND MEDIAL MALLEOLI, OR LATERAL AND POSTERIOR MALLEOLI OR MEDIAL AND POSTERIOR MALLEOLI); WITH MANIPULATION" 27810_3 CDM 360 RC 27810 HCPCS outpatient 968 726 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 823.48 85.07 999999999 755.04 919.6 percent of total billed charges "CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG, LATERAL AND MEDIAL MALLEOLI, OR LATERAL AND POSTERIOR MALLEOLI OR MEDIAL AND POSTERIOR MALLEOLI); WITH MANIPULATION" 27810_3 CDM 360 RC 27810 HCPCS outpatient 968 726 MOLINA MCAID MOLINA MCAID 807.31 83.4 999999999 755.04 919.6 percent of total billed charges "CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG, LATERAL AND MEDIAL MALLEOLI, OR LATERAL AND POSTERIOR MALLEOLI OR MEDIAL AND POSTERIOR MALLEOLI); WITH MANIPULATION" 27810_3 CDM 360 RC 27810 HCPCS outpatient 968 726 MOLINA MCR ADV MOLINA MCR ADV 861.52 89 999999999 755.04 919.6 percent of total billed charges "CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG, LATERAL AND MEDIAL MALLEOLI, OR LATERAL AND POSTERIOR MALLEOLI OR MEDIAL AND POSTERIOR MALLEOLI); WITH MANIPULATION" 27810_3 CDM 360 RC 27810 HCPCS outpatient 968 726 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 861.52 89 999999999 755.04 919.6 percent of total billed charges "CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG, LATERAL AND MEDIAL MALLEOLI, OR LATERAL AND POSTERIOR MALLEOLI OR MEDIAL AND POSTERIOR MALLEOLI); WITH MANIPULATION" 27810_3 CDM 360 RC 27810 HCPCS outpatient 968 726 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 861.52 89 999999999 755.04 919.6 percent of total billed charges "CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG, LATERAL AND MEDIAL MALLEOLI, OR LATERAL AND POSTERIOR MALLEOLI OR MEDIAL AND POSTERIOR MALLEOLI); WITH MANIPULATION" 27810_3 CDM 360 RC 27810 HCPCS outpatient 968 726 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 871.2 90 999999999 755.04 919.6 percent of total billed charges "CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG, LATERAL AND MEDIAL MALLEOLI, OR LATERAL AND POSTERIOR MALLEOLI OR MEDIAL AND POSTERIOR MALLEOLI); WITH MANIPULATION" 27810_3 CDM 360 RC 27810 HCPCS outpatient 968 726 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 919.6 95 999999999 755.04 919.6 percent of total billed charges "CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG, LATERAL AND MEDIAL MALLEOLI, OR LATERAL AND POSTERIOR MALLEOLI OR MEDIAL AND POSTERIOR MALLEOLI); WITH MANIPULATION" 27810_3 CDM 360 RC 27810 HCPCS outpatient 968 726 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 919.6 95 999999999 755.04 919.6 percent of total billed charges "CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG, LATERAL AND MEDIAL MALLEOLI, OR LATERAL AND POSTERIOR MALLEOLI OR MEDIAL AND POSTERIOR MALLEOLI); WITH MANIPULATION" 27810_3 CDM 360 RC 27810 HCPCS outpatient 968 726 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 861.52 89 999999999 755.04 919.6 percent of total billed charges "CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG, LATERAL AND MEDIAL MALLEOLI, OR LATERAL AND POSTERIOR MALLEOLI OR MEDIAL AND POSTERIOR MALLEOLI); WITH MANIPULATION" 27810_3 CDM 360 RC 27810 HCPCS outpatient 968 726 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 851.84 88 999999999 755.04 919.6 percent of total billed charges "CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG, LATERAL AND MEDIAL MALLEOLI, OR LATERAL AND POSTERIOR MALLEOLI OR MEDIAL AND POSTERIOR MALLEOLI); WITH MANIPULATION" 27810_3 CDM 360 RC 27810 HCPCS outpatient 968 726 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 861.52 89 999999999 755.04 919.6 percent of total billed charges CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION 27818_1 CDM 360 RC 27818 HCPCS outpatient 1340.46 1005.35 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1206.41 999999999 1045.56 1273.44 case rate CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION 27818_1 CDM 360 RC 27818 HCPCS outpatient 1340.46 1005.35 AETNA MCR ADV AETNA MCR ADV 1045.56 78 999999999 1045.56 1273.44 percent of total billed charges CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION 27818_1 CDM 360 RC 27818 HCPCS outpatient 1340.46 1005.35 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1173.84 87.57 999999999 1045.56 1273.44 percent of total billed charges CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION 27818_1 CDM 360 RC 27818 HCPCS outpatient 1340.46 1005.35 COORDINATED CARE MCAID COORDINATED CARE MCAID 1140.33 85.07 999999999 1045.56 1273.44 percent of total billed charges CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION 27818_1 CDM 360 RC 27818 HCPCS outpatient 1340.46 1005.35 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1140.33 85.07 999999999 1045.56 1273.44 percent of total billed charges CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION 27818_1 CDM 360 RC 27818 HCPCS outpatient 1340.46 1005.35 MOLINA MCAID MOLINA MCAID 1117.94 83.4 999999999 1045.56 1273.44 percent of total billed charges CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION 27818_1 CDM 360 RC 27818 HCPCS outpatient 1340.46 1005.35 MOLINA MCR ADV MOLINA MCR ADV 1193.01 89 999999999 1045.56 1273.44 percent of total billed charges CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION 27818_1 CDM 360 RC 27818 HCPCS outpatient 1340.46 1005.35 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1193.01 89 999999999 1045.56 1273.44 percent of total billed charges CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION 27818_1 CDM 360 RC 27818 HCPCS outpatient 1340.46 1005.35 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1193.01 89 999999999 1045.56 1273.44 percent of total billed charges CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION 27818_1 CDM 360 RC 27818 HCPCS outpatient 1340.46 1005.35 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1206.41 90 999999999 1045.56 1273.44 percent of total billed charges CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION 27818_1 CDM 360 RC 27818 HCPCS outpatient 1340.46 1005.35 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1273.44 95 999999999 1045.56 1273.44 percent of total billed charges CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION 27818_1 CDM 360 RC 27818 HCPCS outpatient 1340.46 1005.35 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1273.44 95 999999999 1045.56 1273.44 percent of total billed charges CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION 27818_1 CDM 360 RC 27818 HCPCS outpatient 1340.46 1005.35 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1193.01 89 999999999 1045.56 1273.44 percent of total billed charges CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION 27818_1 CDM 360 RC 27818 HCPCS outpatient 1340.46 1005.35 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1179.6 88 999999999 1045.56 1273.44 percent of total billed charges CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION 27818_1 CDM 360 RC 27818 HCPCS outpatient 1340.46 1005.35 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1193.01 89 999999999 1045.56 1273.44 percent of total billed charges "OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION" 27846_1 CDM 360 RC 27846 HCPCS outpatient 2195.07 1646.3 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1975.56 999999999 1712.15 2085.32 case rate "OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION" 27846_1 CDM 360 RC 27846 HCPCS outpatient 2195.07 1646.3 AETNA MCR ADV AETNA MCR ADV 1712.15 78 999999999 1712.15 2085.32 percent of total billed charges "OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION" 27846_1 CDM 360 RC 27846 HCPCS outpatient 2195.07 1646.3 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1922.22 87.57 999999999 1712.15 2085.32 percent of total billed charges "OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION" 27846_1 CDM 360 RC 27846 HCPCS outpatient 2195.07 1646.3 COORDINATED CARE MCAID COORDINATED CARE MCAID 1867.35 85.07 999999999 1712.15 2085.32 percent of total billed charges "OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION" 27846_1 CDM 360 RC 27846 HCPCS outpatient 2195.07 1646.3 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1867.35 85.07 999999999 1712.15 2085.32 percent of total billed charges "OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION" 27846_1 CDM 360 RC 27846 HCPCS outpatient 2195.07 1646.3 MOLINA MCAID MOLINA MCAID 1830.69 83.4 999999999 1712.15 2085.32 percent of total billed charges "OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION" 27846_1 CDM 360 RC 27846 HCPCS outpatient 2195.07 1646.3 MOLINA MCR ADV MOLINA MCR ADV 1953.61 89 999999999 1712.15 2085.32 percent of total billed charges "OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION" 27846_1 CDM 360 RC 27846 HCPCS outpatient 2195.07 1646.3 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1953.61 89 999999999 1712.15 2085.32 percent of total billed charges "OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION" 27846_1 CDM 360 RC 27846 HCPCS outpatient 2195.07 1646.3 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1953.61 89 999999999 1712.15 2085.32 percent of total billed charges "OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION" 27846_1 CDM 360 RC 27846 HCPCS outpatient 2195.07 1646.3 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1975.56 90 999999999 1712.15 2085.32 percent of total billed charges "OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION" 27846_1 CDM 360 RC 27846 HCPCS outpatient 2195.07 1646.3 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 2085.32 95 999999999 1712.15 2085.32 percent of total billed charges "OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION" 27846_1 CDM 360 RC 27846 HCPCS outpatient 2195.07 1646.3 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 2085.32 95 999999999 1712.15 2085.32 percent of total billed charges "OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION" 27846_1 CDM 360 RC 27846 HCPCS outpatient 2195.07 1646.3 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1953.61 89 999999999 1712.15 2085.32 percent of total billed charges "OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION" 27846_1 CDM 360 RC 27846 HCPCS outpatient 2195.07 1646.3 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1931.66 88 999999999 1712.15 2085.32 percent of total billed charges "OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION" 27846_1 CDM 360 RC 27846 HCPCS outpatient 2195.07 1646.3 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1953.61 89 999999999 1712.15 2085.32 percent of total billed charges "REMOVAL OF FOREIGN BODY, FOOT; SUBCUTANEOUS" 28190_3 CDM 360 RC 28190 HCPCS outpatient 502 376.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 451.8 999999999 391.56 476.9 case rate "REMOVAL OF FOREIGN BODY, FOOT; SUBCUTANEOUS" 28190_3 CDM 360 RC 28190 HCPCS outpatient 502 376.5 AETNA MCR ADV AETNA MCR ADV 391.56 78 999999999 391.56 476.9 percent of total billed charges "REMOVAL OF FOREIGN BODY, FOOT; SUBCUTANEOUS" 28190_3 CDM 360 RC 28190 HCPCS outpatient 502 376.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 439.6 87.57 999999999 391.56 476.9 percent of total billed charges "REMOVAL OF FOREIGN BODY, FOOT; SUBCUTANEOUS" 28190_3 CDM 360 RC 28190 HCPCS outpatient 502 376.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 427.05 85.07 999999999 391.56 476.9 percent of total billed charges "REMOVAL OF FOREIGN BODY, FOOT; SUBCUTANEOUS" 28190_3 CDM 360 RC 28190 HCPCS outpatient 502 376.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 427.05 85.07 999999999 391.56 476.9 percent of total billed charges "REMOVAL OF FOREIGN BODY, FOOT; SUBCUTANEOUS" 28190_3 CDM 360 RC 28190 HCPCS outpatient 502 376.5 MOLINA MCAID MOLINA MCAID 418.67 83.4 999999999 391.56 476.9 percent of total billed charges "REMOVAL OF FOREIGN BODY, FOOT; SUBCUTANEOUS" 28190_3 CDM 360 RC 28190 HCPCS outpatient 502 376.5 MOLINA MCR ADV MOLINA MCR ADV 446.78 89 999999999 391.56 476.9 percent of total billed charges "REMOVAL OF FOREIGN BODY, FOOT; SUBCUTANEOUS" 28190_3 CDM 360 RC 28190 HCPCS outpatient 502 376.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 446.78 89 999999999 391.56 476.9 percent of total billed charges "REMOVAL OF FOREIGN BODY, FOOT; SUBCUTANEOUS" 28190_3 CDM 360 RC 28190 HCPCS outpatient 502 376.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 446.78 89 999999999 391.56 476.9 percent of total billed charges "REMOVAL OF FOREIGN BODY, FOOT; SUBCUTANEOUS" 28190_3 CDM 360 RC 28190 HCPCS outpatient 502 376.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 451.8 90 999999999 391.56 476.9 percent of total billed charges "REMOVAL OF FOREIGN BODY, FOOT; SUBCUTANEOUS" 28190_3 CDM 360 RC 28190 HCPCS outpatient 502 376.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 476.9 95 999999999 391.56 476.9 percent of total billed charges "REMOVAL OF FOREIGN BODY, FOOT; SUBCUTANEOUS" 28190_3 CDM 360 RC 28190 HCPCS outpatient 502 376.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 476.9 95 999999999 391.56 476.9 percent of total billed charges "REMOVAL OF FOREIGN BODY, FOOT; SUBCUTANEOUS" 28190_3 CDM 360 RC 28190 HCPCS outpatient 502 376.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 446.78 89 999999999 391.56 476.9 percent of total billed charges "REMOVAL OF FOREIGN BODY, FOOT; SUBCUTANEOUS" 28190_3 CDM 360 RC 28190 HCPCS outpatient 502 376.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 441.76 88 999999999 391.56 476.9 percent of total billed charges "REMOVAL OF FOREIGN BODY, FOOT; SUBCUTANEOUS" 28190_3 CDM 360 RC 28190 HCPCS outpatient 502 376.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 446.78 89 999999999 391.56 476.9 percent of total billed charges "REMOVAL OF FOREIGN BODY, FOOT; DEEP" 28192_3 CDM 360 RC 28192 HCPCS outpatient 942 706.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 847.8 999999999 734.76 894.9 case rate "REMOVAL OF FOREIGN BODY, FOOT; DEEP" 28192_3 CDM 360 RC 28192 HCPCS outpatient 942 706.5 AETNA MCR ADV AETNA MCR ADV 734.76 78 999999999 734.76 894.9 percent of total billed charges "REMOVAL OF FOREIGN BODY, FOOT; DEEP" 28192_3 CDM 360 RC 28192 HCPCS outpatient 942 706.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 824.91 87.57 999999999 734.76 894.9 percent of total billed charges "REMOVAL OF FOREIGN BODY, FOOT; DEEP" 28192_3 CDM 360 RC 28192 HCPCS outpatient 942 706.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 801.36 85.07 999999999 734.76 894.9 percent of total billed charges "REMOVAL OF FOREIGN BODY, FOOT; DEEP" 28192_3 CDM 360 RC 28192 HCPCS outpatient 942 706.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 801.36 85.07 999999999 734.76 894.9 percent of total billed charges "REMOVAL OF FOREIGN BODY, FOOT; DEEP" 28192_3 CDM 360 RC 28192 HCPCS outpatient 942 706.5 MOLINA MCAID MOLINA MCAID 785.63 83.4 999999999 734.76 894.9 percent of total billed charges "REMOVAL OF FOREIGN BODY, FOOT; DEEP" 28192_3 CDM 360 RC 28192 HCPCS outpatient 942 706.5 MOLINA MCR ADV MOLINA MCR ADV 838.38 89 999999999 734.76 894.9 percent of total billed charges "REMOVAL OF FOREIGN BODY, FOOT; DEEP" 28192_3 CDM 360 RC 28192 HCPCS outpatient 942 706.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 838.38 89 999999999 734.76 894.9 percent of total billed charges "REMOVAL OF FOREIGN BODY, FOOT; DEEP" 28192_3 CDM 360 RC 28192 HCPCS outpatient 942 706.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 838.38 89 999999999 734.76 894.9 percent of total billed charges "REMOVAL OF FOREIGN BODY, FOOT; DEEP" 28192_3 CDM 360 RC 28192 HCPCS outpatient 942 706.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 847.8 90 999999999 734.76 894.9 percent of total billed charges "REMOVAL OF FOREIGN BODY, FOOT; DEEP" 28192_3 CDM 360 RC 28192 HCPCS outpatient 942 706.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 894.9 95 999999999 734.76 894.9 percent of total billed charges "REMOVAL OF FOREIGN BODY, FOOT; DEEP" 28192_3 CDM 360 RC 28192 HCPCS outpatient 942 706.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 894.9 95 999999999 734.76 894.9 percent of total billed charges "REMOVAL OF FOREIGN BODY, FOOT; DEEP" 28192_3 CDM 360 RC 28192 HCPCS outpatient 942 706.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 838.38 89 999999999 734.76 894.9 percent of total billed charges "REMOVAL OF FOREIGN BODY, FOOT; DEEP" 28192_3 CDM 360 RC 28192 HCPCS outpatient 942 706.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 828.96 88 999999999 734.76 894.9 percent of total billed charges "REMOVAL OF FOREIGN BODY, FOOT; DEEP" 28192_3 CDM 360 RC 28192 HCPCS outpatient 942 706.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 838.38 89 999999999 734.76 894.9 percent of total billed charges "APPLICATION, CAST; SHOULDER TO HAND (LONG ARM)" 29065_3 CDM 360 RC 29065 HCPCS outpatient 194 145.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 174.6 999999999 151.32 184.3 case rate "APPLICATION, CAST; SHOULDER TO HAND (LONG ARM)" 29065_3 CDM 360 RC 29065 HCPCS outpatient 194 145.5 AETNA MCR ADV AETNA MCR ADV 151.32 78 999999999 151.32 184.3 percent of total billed charges "APPLICATION, CAST; SHOULDER TO HAND (LONG ARM)" 29065_3 CDM 360 RC 29065 HCPCS outpatient 194 145.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 169.89 87.57 999999999 151.32 184.3 percent of total billed charges "APPLICATION, CAST; SHOULDER TO HAND (LONG ARM)" 29065_3 CDM 360 RC 29065 HCPCS outpatient 194 145.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 165.04 85.07 999999999 151.32 184.3 percent of total billed charges "APPLICATION, CAST; SHOULDER TO HAND (LONG ARM)" 29065_3 CDM 360 RC 29065 HCPCS outpatient 194 145.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 165.04 85.07 999999999 151.32 184.3 percent of total billed charges "APPLICATION, CAST; SHOULDER TO HAND (LONG ARM)" 29065_3 CDM 360 RC 29065 HCPCS outpatient 194 145.5 MOLINA MCAID MOLINA MCAID 161.8 83.4 999999999 151.32 184.3 percent of total billed charges "APPLICATION, CAST; SHOULDER TO HAND (LONG ARM)" 29065_3 CDM 360 RC 29065 HCPCS outpatient 194 145.5 MOLINA MCR ADV MOLINA MCR ADV 172.66 89 999999999 151.32 184.3 percent of total billed charges "APPLICATION, CAST; SHOULDER TO HAND (LONG ARM)" 29065_3 CDM 360 RC 29065 HCPCS outpatient 194 145.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 172.66 89 999999999 151.32 184.3 percent of total billed charges "APPLICATION, CAST; SHOULDER TO HAND (LONG ARM)" 29065_3 CDM 360 RC 29065 HCPCS outpatient 194 145.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 172.66 89 999999999 151.32 184.3 percent of total billed charges "APPLICATION, CAST; SHOULDER TO HAND (LONG ARM)" 29065_3 CDM 360 RC 29065 HCPCS outpatient 194 145.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 174.6 90 999999999 151.32 184.3 percent of total billed charges "APPLICATION, CAST; SHOULDER TO HAND (LONG ARM)" 29065_3 CDM 360 RC 29065 HCPCS outpatient 194 145.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 184.3 95 999999999 151.32 184.3 percent of total billed charges "APPLICATION, CAST; SHOULDER TO HAND (LONG ARM)" 29065_3 CDM 360 RC 29065 HCPCS outpatient 194 145.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 184.3 95 999999999 151.32 184.3 percent of total billed charges "APPLICATION, CAST; SHOULDER TO HAND (LONG ARM)" 29065_3 CDM 360 RC 29065 HCPCS outpatient 194 145.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 172.66 89 999999999 151.32 184.3 percent of total billed charges "APPLICATION, CAST; SHOULDER TO HAND (LONG ARM)" 29065_3 CDM 360 RC 29065 HCPCS outpatient 194 145.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 170.72 88 999999999 151.32 184.3 percent of total billed charges "APPLICATION, CAST; SHOULDER TO HAND (LONG ARM)" 29065_3 CDM 360 RC 29065 HCPCS outpatient 194 145.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 172.66 89 999999999 151.32 184.3 percent of total billed charges "APPLICATION, CAST; ELBOW TO FINGER (SHORT ARM)" 29075_3 CDM 360 RC 29075 HCPCS outpatient 174 130.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 156.6 999999999 135.72 165.3 case rate "APPLICATION, CAST; ELBOW TO FINGER (SHORT ARM)" 29075_3 CDM 360 RC 29075 HCPCS outpatient 174 130.5 AETNA MCR ADV AETNA MCR ADV 135.72 78 999999999 135.72 165.3 percent of total billed charges "APPLICATION, CAST; ELBOW TO FINGER (SHORT ARM)" 29075_3 CDM 360 RC 29075 HCPCS outpatient 174 130.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 152.37 87.57 999999999 135.72 165.3 percent of total billed charges "APPLICATION, CAST; ELBOW TO FINGER (SHORT ARM)" 29075_3 CDM 360 RC 29075 HCPCS outpatient 174 130.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 148.02 85.07 999999999 135.72 165.3 percent of total billed charges "APPLICATION, CAST; ELBOW TO FINGER (SHORT ARM)" 29075_3 CDM 360 RC 29075 HCPCS outpatient 174 130.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 148.02 85.07 999999999 135.72 165.3 percent of total billed charges "APPLICATION, CAST; ELBOW TO FINGER (SHORT ARM)" 29075_3 CDM 360 RC 29075 HCPCS outpatient 174 130.5 MOLINA MCAID MOLINA MCAID 145.12 83.4 999999999 135.72 165.3 percent of total billed charges "APPLICATION, CAST; ELBOW TO FINGER (SHORT ARM)" 29075_3 CDM 360 RC 29075 HCPCS outpatient 174 130.5 MOLINA MCR ADV MOLINA MCR ADV 154.86 89 999999999 135.72 165.3 percent of total billed charges "APPLICATION, CAST; ELBOW TO FINGER (SHORT ARM)" 29075_3 CDM 360 RC 29075 HCPCS outpatient 174 130.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 154.86 89 999999999 135.72 165.3 percent of total billed charges "APPLICATION, CAST; ELBOW TO FINGER (SHORT ARM)" 29075_3 CDM 360 RC 29075 HCPCS outpatient 174 130.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 154.86 89 999999999 135.72 165.3 percent of total billed charges "APPLICATION, CAST; ELBOW TO FINGER (SHORT ARM)" 29075_3 CDM 360 RC 29075 HCPCS outpatient 174 130.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 156.6 90 999999999 135.72 165.3 percent of total billed charges "APPLICATION, CAST; ELBOW TO FINGER (SHORT ARM)" 29075_3 CDM 360 RC 29075 HCPCS outpatient 174 130.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 165.3 95 999999999 135.72 165.3 percent of total billed charges "APPLICATION, CAST; ELBOW TO FINGER (SHORT ARM)" 29075_3 CDM 360 RC 29075 HCPCS outpatient 174 130.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 165.3 95 999999999 135.72 165.3 percent of total billed charges "APPLICATION, CAST; ELBOW TO FINGER (SHORT ARM)" 29075_3 CDM 360 RC 29075 HCPCS outpatient 174 130.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 154.86 89 999999999 135.72 165.3 percent of total billed charges "APPLICATION, CAST; ELBOW TO FINGER (SHORT ARM)" 29075_3 CDM 360 RC 29075 HCPCS outpatient 174 130.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 153.12 88 999999999 135.72 165.3 percent of total billed charges "APPLICATION, CAST; ELBOW TO FINGER (SHORT ARM)" 29075_3 CDM 360 RC 29075 HCPCS outpatient 174 130.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 154.86 89 999999999 135.72 165.3 percent of total billed charges "APPLICATION, CAST; HAND AND LOWER FOREARM (GAUNTLET)" 29085_3 CDM 360 RC 29085 HCPCS outpatient 192 144 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 172.8 999999999 149.76 182.4 case rate "APPLICATION, CAST; HAND AND LOWER FOREARM (GAUNTLET)" 29085_3 CDM 360 RC 29085 HCPCS outpatient 192 144 AETNA MCR ADV AETNA MCR ADV 149.76 78 999999999 149.76 182.4 percent of total billed charges "APPLICATION, CAST; HAND AND LOWER FOREARM (GAUNTLET)" 29085_3 CDM 360 RC 29085 HCPCS outpatient 192 144 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 168.13 87.57 999999999 149.76 182.4 percent of total billed charges "APPLICATION, CAST; HAND AND LOWER FOREARM (GAUNTLET)" 29085_3 CDM 360 RC 29085 HCPCS outpatient 192 144 COORDINATED CARE MCAID COORDINATED CARE MCAID 163.33 85.07 999999999 149.76 182.4 percent of total billed charges "APPLICATION, CAST; HAND AND LOWER FOREARM (GAUNTLET)" 29085_3 CDM 360 RC 29085 HCPCS outpatient 192 144 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 163.33 85.07 999999999 149.76 182.4 percent of total billed charges "APPLICATION, CAST; HAND AND LOWER FOREARM (GAUNTLET)" 29085_3 CDM 360 RC 29085 HCPCS outpatient 192 144 MOLINA MCAID MOLINA MCAID 160.13 83.4 999999999 149.76 182.4 percent of total billed charges "APPLICATION, CAST; HAND AND LOWER FOREARM (GAUNTLET)" 29085_3 CDM 360 RC 29085 HCPCS outpatient 192 144 MOLINA MCR ADV MOLINA MCR ADV 170.88 89 999999999 149.76 182.4 percent of total billed charges "APPLICATION, CAST; HAND AND LOWER FOREARM (GAUNTLET)" 29085_3 CDM 360 RC 29085 HCPCS outpatient 192 144 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 170.88 89 999999999 149.76 182.4 percent of total billed charges "APPLICATION, CAST; HAND AND LOWER FOREARM (GAUNTLET)" 29085_3 CDM 360 RC 29085 HCPCS outpatient 192 144 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 170.88 89 999999999 149.76 182.4 percent of total billed charges "APPLICATION, CAST; HAND AND LOWER FOREARM (GAUNTLET)" 29085_3 CDM 360 RC 29085 HCPCS outpatient 192 144 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 172.8 90 999999999 149.76 182.4 percent of total billed charges "APPLICATION, CAST; HAND AND LOWER FOREARM (GAUNTLET)" 29085_3 CDM 360 RC 29085 HCPCS outpatient 192 144 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 182.4 95 999999999 149.76 182.4 percent of total billed charges "APPLICATION, CAST; HAND AND LOWER FOREARM (GAUNTLET)" 29085_3 CDM 360 RC 29085 HCPCS outpatient 192 144 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 182.4 95 999999999 149.76 182.4 percent of total billed charges "APPLICATION, CAST; HAND AND LOWER FOREARM (GAUNTLET)" 29085_3 CDM 360 RC 29085 HCPCS outpatient 192 144 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 170.88 89 999999999 149.76 182.4 percent of total billed charges "APPLICATION, CAST; HAND AND LOWER FOREARM (GAUNTLET)" 29085_3 CDM 360 RC 29085 HCPCS outpatient 192 144 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 168.96 88 999999999 149.76 182.4 percent of total billed charges "APPLICATION, CAST; HAND AND LOWER FOREARM (GAUNTLET)" 29085_3 CDM 360 RC 29085 HCPCS outpatient 192 144 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 170.88 89 999999999 149.76 182.4 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 29105_1 CDM 360 RC 29105 HCPCS outpatient 123.33 92.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 111 999999999 96.2 117.16 case rate APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 29105_1 CDM 360 RC 29105 HCPCS outpatient 123.33 92.5 AETNA MCR ADV AETNA MCR ADV 96.2 78 999999999 96.2 117.16 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 29105_1 CDM 360 RC 29105 HCPCS outpatient 123.33 92.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 108 87.57 999999999 96.2 117.16 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 29105_1 CDM 360 RC 29105 HCPCS outpatient 123.33 92.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 104.92 85.07 999999999 96.2 117.16 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 29105_1 CDM 360 RC 29105 HCPCS outpatient 123.33 92.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 104.92 85.07 999999999 96.2 117.16 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 29105_1 CDM 360 RC 29105 HCPCS outpatient 123.33 92.5 MOLINA MCAID MOLINA MCAID 102.86 83.4 999999999 96.2 117.16 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 29105_1 CDM 360 RC 29105 HCPCS outpatient 123.33 92.5 MOLINA MCR ADV MOLINA MCR ADV 109.76 89 999999999 96.2 117.16 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 29105_1 CDM 360 RC 29105 HCPCS outpatient 123.33 92.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 109.76 89 999999999 96.2 117.16 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 29105_1 CDM 360 RC 29105 HCPCS outpatient 123.33 92.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 109.76 89 999999999 96.2 117.16 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 29105_1 CDM 360 RC 29105 HCPCS outpatient 123.33 92.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 111 90 999999999 96.2 117.16 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 29105_1 CDM 360 RC 29105 HCPCS outpatient 123.33 92.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 117.16 95 999999999 96.2 117.16 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 29105_1 CDM 360 RC 29105 HCPCS outpatient 123.33 92.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 117.16 95 999999999 96.2 117.16 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 29105_1 CDM 360 RC 29105 HCPCS outpatient 123.33 92.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 109.76 89 999999999 96.2 117.16 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 29105_1 CDM 360 RC 29105 HCPCS outpatient 123.33 92.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 108.53 88 999999999 96.2 117.16 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 29105_1 CDM 360 RC 29105 HCPCS outpatient 123.33 92.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 109.76 89 999999999 96.2 117.16 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 29105_2 CDM 360 RC 29105 HCPCS outpatient 123.33 92.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 111 999999999 96.2 117.16 case rate APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 29105_2 CDM 360 RC 29105 HCPCS outpatient 123.33 92.5 AETNA MCR ADV AETNA MCR ADV 96.2 78 999999999 96.2 117.16 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 29105_2 CDM 360 RC 29105 HCPCS outpatient 123.33 92.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 108 87.57 999999999 96.2 117.16 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 29105_2 CDM 360 RC 29105 HCPCS outpatient 123.33 92.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 104.92 85.07 999999999 96.2 117.16 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 29105_2 CDM 360 RC 29105 HCPCS outpatient 123.33 92.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 104.92 85.07 999999999 96.2 117.16 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 29105_2 CDM 360 RC 29105 HCPCS outpatient 123.33 92.5 MOLINA MCAID MOLINA MCAID 102.86 83.4 999999999 96.2 117.16 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 29105_2 CDM 360 RC 29105 HCPCS outpatient 123.33 92.5 MOLINA MCR ADV MOLINA MCR ADV 109.76 89 999999999 96.2 117.16 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 29105_2 CDM 360 RC 29105 HCPCS outpatient 123.33 92.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 109.76 89 999999999 96.2 117.16 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 29105_2 CDM 360 RC 29105 HCPCS outpatient 123.33 92.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 109.76 89 999999999 96.2 117.16 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 29105_2 CDM 360 RC 29105 HCPCS outpatient 123.33 92.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 111 90 999999999 96.2 117.16 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 29105_2 CDM 360 RC 29105 HCPCS outpatient 123.33 92.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 117.16 95 999999999 96.2 117.16 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 29105_2 CDM 360 RC 29105 HCPCS outpatient 123.33 92.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 117.16 95 999999999 96.2 117.16 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 29105_2 CDM 360 RC 29105 HCPCS outpatient 123.33 92.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 109.76 89 999999999 96.2 117.16 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 29105_2 CDM 360 RC 29105 HCPCS outpatient 123.33 92.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 108.53 88 999999999 96.2 117.16 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 29105_2 CDM 360 RC 29105 HCPCS outpatient 123.33 92.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 109.76 89 999999999 96.2 117.16 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_1 CDM 360 RC 29125 HCPCS outpatient 119.91 89.93 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 107.92 999999999 93.53 113.91 case rate APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_1 CDM 360 RC 29125 HCPCS outpatient 119.91 89.93 AETNA MCR ADV AETNA MCR ADV 93.53 78 999999999 93.53 113.91 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_1 CDM 360 RC 29125 HCPCS outpatient 119.91 89.93 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 105.01 87.57 999999999 93.53 113.91 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_1 CDM 360 RC 29125 HCPCS outpatient 119.91 89.93 COORDINATED CARE MCAID COORDINATED CARE MCAID 102.01 85.07 999999999 93.53 113.91 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_1 CDM 360 RC 29125 HCPCS outpatient 119.91 89.93 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 102.01 85.07 999999999 93.53 113.91 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_1 CDM 360 RC 29125 HCPCS outpatient 119.91 89.93 MOLINA MCAID MOLINA MCAID 100 83.4 999999999 93.53 113.91 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_1 CDM 360 RC 29125 HCPCS outpatient 119.91 89.93 MOLINA MCR ADV MOLINA MCR ADV 106.72 89 999999999 93.53 113.91 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_1 CDM 360 RC 29125 HCPCS outpatient 119.91 89.93 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 106.72 89 999999999 93.53 113.91 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_1 CDM 360 RC 29125 HCPCS outpatient 119.91 89.93 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 106.72 89 999999999 93.53 113.91 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_1 CDM 360 RC 29125 HCPCS outpatient 119.91 89.93 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 107.92 90 999999999 93.53 113.91 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_1 CDM 360 RC 29125 HCPCS outpatient 119.91 89.93 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 113.91 95 999999999 93.53 113.91 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_1 CDM 360 RC 29125 HCPCS outpatient 119.91 89.93 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 113.91 95 999999999 93.53 113.91 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_1 CDM 360 RC 29125 HCPCS outpatient 119.91 89.93 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 106.72 89 999999999 93.53 113.91 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_1 CDM 360 RC 29125 HCPCS outpatient 119.91 89.93 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 105.52 88 999999999 93.53 113.91 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_1 CDM 360 RC 29125 HCPCS outpatient 119.91 89.93 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 106.72 89 999999999 93.53 113.91 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_2 CDM 360 RC 29125 HCPCS outpatient 119.91 89.93 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 107.92 999999999 93.53 113.91 case rate APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_2 CDM 360 RC 29125 HCPCS outpatient 119.91 89.93 AETNA MCR ADV AETNA MCR ADV 93.53 78 999999999 93.53 113.91 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_2 CDM 360 RC 29125 HCPCS outpatient 119.91 89.93 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 105.01 87.57 999999999 93.53 113.91 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_2 CDM 360 RC 29125 HCPCS outpatient 119.91 89.93 COORDINATED CARE MCAID COORDINATED CARE MCAID 102.01 85.07 999999999 93.53 113.91 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_2 CDM 360 RC 29125 HCPCS outpatient 119.91 89.93 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 102.01 85.07 999999999 93.53 113.91 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_2 CDM 360 RC 29125 HCPCS outpatient 119.91 89.93 MOLINA MCAID MOLINA MCAID 100 83.4 999999999 93.53 113.91 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_2 CDM 360 RC 29125 HCPCS outpatient 119.91 89.93 MOLINA MCR ADV MOLINA MCR ADV 106.72 89 999999999 93.53 113.91 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_2 CDM 360 RC 29125 HCPCS outpatient 119.91 89.93 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 106.72 89 999999999 93.53 113.91 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_2 CDM 360 RC 29125 HCPCS outpatient 119.91 89.93 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 106.72 89 999999999 93.53 113.91 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_2 CDM 360 RC 29125 HCPCS outpatient 119.91 89.93 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 107.92 90 999999999 93.53 113.91 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_2 CDM 360 RC 29125 HCPCS outpatient 119.91 89.93 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 113.91 95 999999999 93.53 113.91 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_2 CDM 360 RC 29125 HCPCS outpatient 119.91 89.93 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 113.91 95 999999999 93.53 113.91 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_2 CDM 360 RC 29125 HCPCS outpatient 119.91 89.93 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 106.72 89 999999999 93.53 113.91 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_2 CDM 360 RC 29125 HCPCS outpatient 119.91 89.93 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 105.52 88 999999999 93.53 113.91 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_2 CDM 360 RC 29125 HCPCS outpatient 119.91 89.93 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 106.72 89 999999999 93.53 113.91 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_3 CDM 360 RC 29125 HCPCS outpatient 132 99 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 118.8 999999999 102.96 125.4 case rate APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_3 CDM 360 RC 29125 HCPCS outpatient 132 99 AETNA MCR ADV AETNA MCR ADV 102.96 78 999999999 102.96 125.4 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_3 CDM 360 RC 29125 HCPCS outpatient 132 99 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 115.59 87.57 999999999 102.96 125.4 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_3 CDM 360 RC 29125 HCPCS outpatient 132 99 COORDINATED CARE MCAID COORDINATED CARE MCAID 112.29 85.07 999999999 102.96 125.4 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_3 CDM 360 RC 29125 HCPCS outpatient 132 99 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 112.29 85.07 999999999 102.96 125.4 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_3 CDM 360 RC 29125 HCPCS outpatient 132 99 MOLINA MCAID MOLINA MCAID 110.09 83.4 999999999 102.96 125.4 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_3 CDM 360 RC 29125 HCPCS outpatient 132 99 MOLINA MCR ADV MOLINA MCR ADV 117.48 89 999999999 102.96 125.4 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_3 CDM 360 RC 29125 HCPCS outpatient 132 99 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 117.48 89 999999999 102.96 125.4 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_3 CDM 360 RC 29125 HCPCS outpatient 132 99 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 117.48 89 999999999 102.96 125.4 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_3 CDM 360 RC 29125 HCPCS outpatient 132 99 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 118.8 90 999999999 102.96 125.4 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_3 CDM 360 RC 29125 HCPCS outpatient 132 99 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 125.4 95 999999999 102.96 125.4 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_3 CDM 360 RC 29125 HCPCS outpatient 132 99 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 125.4 95 999999999 102.96 125.4 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_3 CDM 360 RC 29125 HCPCS outpatient 132 99 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 117.48 89 999999999 102.96 125.4 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_3 CDM 360 RC 29125 HCPCS outpatient 132 99 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 116.16 88 999999999 102.96 125.4 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29125_3 CDM 360 RC 29125 HCPCS outpatient 132 99 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 117.48 89 999999999 102.96 125.4 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 29130_1 CDM 360 RC 29130 HCPCS outpatient 87.27 65.45 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 78.54 999999999 68.07 82.91 case rate APPLICATION OF FINGER SPLINT; STATIC 29130_1 CDM 360 RC 29130 HCPCS outpatient 87.27 65.45 AETNA MCR ADV AETNA MCR ADV 68.07 78 999999999 68.07 82.91 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 29130_1 CDM 360 RC 29130 HCPCS outpatient 87.27 65.45 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 76.42 87.57 999999999 68.07 82.91 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 29130_1 CDM 360 RC 29130 HCPCS outpatient 87.27 65.45 COORDINATED CARE MCAID COORDINATED CARE MCAID 74.24 85.07 999999999 68.07 82.91 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 29130_1 CDM 360 RC 29130 HCPCS outpatient 87.27 65.45 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 74.24 85.07 999999999 68.07 82.91 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 29130_1 CDM 360 RC 29130 HCPCS outpatient 87.27 65.45 MOLINA MCAID MOLINA MCAID 72.78 83.4 999999999 68.07 82.91 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 29130_1 CDM 360 RC 29130 HCPCS outpatient 87.27 65.45 MOLINA MCR ADV MOLINA MCR ADV 77.67 89 999999999 68.07 82.91 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 29130_1 CDM 360 RC 29130 HCPCS outpatient 87.27 65.45 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 77.67 89 999999999 68.07 82.91 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 29130_1 CDM 360 RC 29130 HCPCS outpatient 87.27 65.45 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 77.67 89 999999999 68.07 82.91 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 29130_1 CDM 360 RC 29130 HCPCS outpatient 87.27 65.45 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 78.54 90 999999999 68.07 82.91 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 29130_1 CDM 360 RC 29130 HCPCS outpatient 87.27 65.45 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 82.91 95 999999999 68.07 82.91 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 29130_1 CDM 360 RC 29130 HCPCS outpatient 87.27 65.45 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 82.91 95 999999999 68.07 82.91 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 29130_1 CDM 360 RC 29130 HCPCS outpatient 87.27 65.45 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 77.67 89 999999999 68.07 82.91 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 29130_1 CDM 360 RC 29130 HCPCS outpatient 87.27 65.45 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 76.8 88 999999999 68.07 82.91 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 29130_1 CDM 360 RC 29130 HCPCS outpatient 87.27 65.45 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 77.67 89 999999999 68.07 82.91 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 29130_2 CDM 360 RC 29130 HCPCS outpatient 87.27 65.45 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 78.54 999999999 68.07 82.91 case rate APPLICATION OF FINGER SPLINT; STATIC 29130_2 CDM 360 RC 29130 HCPCS outpatient 87.27 65.45 AETNA MCR ADV AETNA MCR ADV 68.07 78 999999999 68.07 82.91 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 29130_2 CDM 360 RC 29130 HCPCS outpatient 87.27 65.45 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 76.42 87.57 999999999 68.07 82.91 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 29130_2 CDM 360 RC 29130 HCPCS outpatient 87.27 65.45 COORDINATED CARE MCAID COORDINATED CARE MCAID 74.24 85.07 999999999 68.07 82.91 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 29130_2 CDM 360 RC 29130 HCPCS outpatient 87.27 65.45 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 74.24 85.07 999999999 68.07 82.91 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 29130_2 CDM 360 RC 29130 HCPCS outpatient 87.27 65.45 MOLINA MCAID MOLINA MCAID 72.78 83.4 999999999 68.07 82.91 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 29130_2 CDM 360 RC 29130 HCPCS outpatient 87.27 65.45 MOLINA MCR ADV MOLINA MCR ADV 77.67 89 999999999 68.07 82.91 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 29130_2 CDM 360 RC 29130 HCPCS outpatient 87.27 65.45 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 77.67 89 999999999 68.07 82.91 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 29130_2 CDM 360 RC 29130 HCPCS outpatient 87.27 65.45 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 77.67 89 999999999 68.07 82.91 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 29130_2 CDM 360 RC 29130 HCPCS outpatient 87.27 65.45 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 78.54 90 999999999 68.07 82.91 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 29130_2 CDM 360 RC 29130 HCPCS outpatient 87.27 65.45 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 82.91 95 999999999 68.07 82.91 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 29130_2 CDM 360 RC 29130 HCPCS outpatient 87.27 65.45 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 82.91 95 999999999 68.07 82.91 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 29130_2 CDM 360 RC 29130 HCPCS outpatient 87.27 65.45 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 77.67 89 999999999 68.07 82.91 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 29130_2 CDM 360 RC 29130 HCPCS outpatient 87.27 65.45 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 76.8 88 999999999 68.07 82.91 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 29130_2 CDM 360 RC 29130 HCPCS outpatient 87.27 65.45 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 77.67 89 999999999 68.07 82.91 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 29130_3 CDM 360 RC 29130 HCPCS outpatient 83 62.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 74.7 999999999 64.74 78.85 case rate APPLICATION OF FINGER SPLINT; STATIC 29130_3 CDM 360 RC 29130 HCPCS outpatient 83 62.25 AETNA MCR ADV AETNA MCR ADV 64.74 78 999999999 64.74 78.85 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 29130_3 CDM 360 RC 29130 HCPCS outpatient 83 62.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 72.68 87.57 999999999 64.74 78.85 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 29130_3 CDM 360 RC 29130 HCPCS outpatient 83 62.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 70.61 85.07 999999999 64.74 78.85 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 29130_3 CDM 360 RC 29130 HCPCS outpatient 83 62.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 70.61 85.07 999999999 64.74 78.85 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 29130_3 CDM 360 RC 29130 HCPCS outpatient 83 62.25 MOLINA MCAID MOLINA MCAID 69.22 83.4 999999999 64.74 78.85 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 29130_3 CDM 360 RC 29130 HCPCS outpatient 83 62.25 MOLINA MCR ADV MOLINA MCR ADV 73.87 89 999999999 64.74 78.85 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 29130_3 CDM 360 RC 29130 HCPCS outpatient 83 62.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 73.87 89 999999999 64.74 78.85 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 29130_3 CDM 360 RC 29130 HCPCS outpatient 83 62.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 73.87 89 999999999 64.74 78.85 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 29130_3 CDM 360 RC 29130 HCPCS outpatient 83 62.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 74.7 90 999999999 64.74 78.85 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 29130_3 CDM 360 RC 29130 HCPCS outpatient 83 62.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 78.85 95 999999999 64.74 78.85 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 29130_3 CDM 360 RC 29130 HCPCS outpatient 83 62.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 78.85 95 999999999 64.74 78.85 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 29130_3 CDM 360 RC 29130 HCPCS outpatient 83 62.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 73.87 89 999999999 64.74 78.85 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 29130_3 CDM 360 RC 29130 HCPCS outpatient 83 62.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 73.04 88 999999999 64.74 78.85 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 29130_3 CDM 360 RC 29130 HCPCS outpatient 83 62.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 73.87 89 999999999 64.74 78.85 percent of total billed charges APPLICATION OF LONG LEG CAST (THIGH TO TOES) 29345_3 CDM 360 RC 29345 HCPCS outpatient 172 129 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 154.8 999999999 134.16 163.4 case rate APPLICATION OF LONG LEG CAST (THIGH TO TOES) 29345_3 CDM 360 RC 29345 HCPCS outpatient 172 129 AETNA MCR ADV AETNA MCR ADV 134.16 78 999999999 134.16 163.4 percent of total billed charges APPLICATION OF LONG LEG CAST (THIGH TO TOES) 29345_3 CDM 360 RC 29345 HCPCS outpatient 172 129 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 150.62 87.57 999999999 134.16 163.4 percent of total billed charges APPLICATION OF LONG LEG CAST (THIGH TO TOES) 29345_3 CDM 360 RC 29345 HCPCS outpatient 172 129 COORDINATED CARE MCAID COORDINATED CARE MCAID 146.32 85.07 999999999 134.16 163.4 percent of total billed charges APPLICATION OF LONG LEG CAST (THIGH TO TOES) 29345_3 CDM 360 RC 29345 HCPCS outpatient 172 129 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 146.32 85.07 999999999 134.16 163.4 percent of total billed charges APPLICATION OF LONG LEG CAST (THIGH TO TOES) 29345_3 CDM 360 RC 29345 HCPCS outpatient 172 129 MOLINA MCAID MOLINA MCAID 143.45 83.4 999999999 134.16 163.4 percent of total billed charges APPLICATION OF LONG LEG CAST (THIGH TO TOES) 29345_3 CDM 360 RC 29345 HCPCS outpatient 172 129 MOLINA MCR ADV MOLINA MCR ADV 153.08 89 999999999 134.16 163.4 percent of total billed charges APPLICATION OF LONG LEG CAST (THIGH TO TOES) 29345_3 CDM 360 RC 29345 HCPCS outpatient 172 129 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 153.08 89 999999999 134.16 163.4 percent of total billed charges APPLICATION OF LONG LEG CAST (THIGH TO TOES) 29345_3 CDM 360 RC 29345 HCPCS outpatient 172 129 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 153.08 89 999999999 134.16 163.4 percent of total billed charges APPLICATION OF LONG LEG CAST (THIGH TO TOES) 29345_3 CDM 360 RC 29345 HCPCS outpatient 172 129 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 154.8 90 999999999 134.16 163.4 percent of total billed charges APPLICATION OF LONG LEG CAST (THIGH TO TOES) 29345_3 CDM 360 RC 29345 HCPCS outpatient 172 129 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 163.4 95 999999999 134.16 163.4 percent of total billed charges APPLICATION OF LONG LEG CAST (THIGH TO TOES) 29345_3 CDM 360 RC 29345 HCPCS outpatient 172 129 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 163.4 95 999999999 134.16 163.4 percent of total billed charges APPLICATION OF LONG LEG CAST (THIGH TO TOES) 29345_3 CDM 360 RC 29345 HCPCS outpatient 172 129 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 153.08 89 999999999 134.16 163.4 percent of total billed charges APPLICATION OF LONG LEG CAST (THIGH TO TOES) 29345_3 CDM 360 RC 29345 HCPCS outpatient 172 129 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 151.36 88 999999999 134.16 163.4 percent of total billed charges APPLICATION OF LONG LEG CAST (THIGH TO TOES) 29345_3 CDM 360 RC 29345 HCPCS outpatient 172 129 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 153.08 89 999999999 134.16 163.4 percent of total billed charges APPLICATION OF LONG LEG CAST (THIGH TO TOES); WALKER OR AMBULATORY TYPE 29355_3 CDM 360 RC 29355 HCPCS outpatient 286 214.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 257.4 999999999 223.08 271.7 case rate APPLICATION OF LONG LEG CAST (THIGH TO TOES); WALKER OR AMBULATORY TYPE 29355_3 CDM 360 RC 29355 HCPCS outpatient 286 214.5 AETNA MCR ADV AETNA MCR ADV 223.08 78 999999999 223.08 271.7 percent of total billed charges APPLICATION OF LONG LEG CAST (THIGH TO TOES); WALKER OR AMBULATORY TYPE 29355_3 CDM 360 RC 29355 HCPCS outpatient 286 214.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 250.45 87.57 999999999 223.08 271.7 percent of total billed charges APPLICATION OF LONG LEG CAST (THIGH TO TOES); WALKER OR AMBULATORY TYPE 29355_3 CDM 360 RC 29355 HCPCS outpatient 286 214.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 243.3 85.07 999999999 223.08 271.7 percent of total billed charges APPLICATION OF LONG LEG CAST (THIGH TO TOES); WALKER OR AMBULATORY TYPE 29355_3 CDM 360 RC 29355 HCPCS outpatient 286 214.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 243.3 85.07 999999999 223.08 271.7 percent of total billed charges APPLICATION OF LONG LEG CAST (THIGH TO TOES); WALKER OR AMBULATORY TYPE 29355_3 CDM 360 RC 29355 HCPCS outpatient 286 214.5 MOLINA MCAID MOLINA MCAID 238.52 83.4 999999999 223.08 271.7 percent of total billed charges APPLICATION OF LONG LEG CAST (THIGH TO TOES); WALKER OR AMBULATORY TYPE 29355_3 CDM 360 RC 29355 HCPCS outpatient 286 214.5 MOLINA MCR ADV MOLINA MCR ADV 254.54 89 999999999 223.08 271.7 percent of total billed charges APPLICATION OF LONG LEG CAST (THIGH TO TOES); WALKER OR AMBULATORY TYPE 29355_3 CDM 360 RC 29355 HCPCS outpatient 286 214.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 254.54 89 999999999 223.08 271.7 percent of total billed charges APPLICATION OF LONG LEG CAST (THIGH TO TOES); WALKER OR AMBULATORY TYPE 29355_3 CDM 360 RC 29355 HCPCS outpatient 286 214.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 254.54 89 999999999 223.08 271.7 percent of total billed charges APPLICATION OF LONG LEG CAST (THIGH TO TOES); WALKER OR AMBULATORY TYPE 29355_3 CDM 360 RC 29355 HCPCS outpatient 286 214.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 257.4 90 999999999 223.08 271.7 percent of total billed charges APPLICATION OF LONG LEG CAST (THIGH TO TOES); WALKER OR AMBULATORY TYPE 29355_3 CDM 360 RC 29355 HCPCS outpatient 286 214.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 271.7 95 999999999 223.08 271.7 percent of total billed charges APPLICATION OF LONG LEG CAST (THIGH TO TOES); WALKER OR AMBULATORY TYPE 29355_3 CDM 360 RC 29355 HCPCS outpatient 286 214.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 271.7 95 999999999 223.08 271.7 percent of total billed charges APPLICATION OF LONG LEG CAST (THIGH TO TOES); WALKER OR AMBULATORY TYPE 29355_3 CDM 360 RC 29355 HCPCS outpatient 286 214.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 254.54 89 999999999 223.08 271.7 percent of total billed charges APPLICATION OF LONG LEG CAST (THIGH TO TOES); WALKER OR AMBULATORY TYPE 29355_3 CDM 360 RC 29355 HCPCS outpatient 286 214.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 251.68 88 999999999 223.08 271.7 percent of total billed charges APPLICATION OF LONG LEG CAST (THIGH TO TOES); WALKER OR AMBULATORY TYPE 29355_3 CDM 360 RC 29355 HCPCS outpatient 286 214.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 254.54 89 999999999 223.08 271.7 percent of total billed charges APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES) 29405_3 CDM 360 RC 29405 HCPCS outpatient 162 121.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 145.8 999999999 126.36 153.9 case rate APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES) 29405_3 CDM 360 RC 29405 HCPCS outpatient 162 121.5 AETNA MCR ADV AETNA MCR ADV 126.36 78 999999999 126.36 153.9 percent of total billed charges APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES) 29405_3 CDM 360 RC 29405 HCPCS outpatient 162 121.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 141.86 87.57 999999999 126.36 153.9 percent of total billed charges APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES) 29405_3 CDM 360 RC 29405 HCPCS outpatient 162 121.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 137.81 85.07 999999999 126.36 153.9 percent of total billed charges APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES) 29405_3 CDM 360 RC 29405 HCPCS outpatient 162 121.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 137.81 85.07 999999999 126.36 153.9 percent of total billed charges APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES) 29405_3 CDM 360 RC 29405 HCPCS outpatient 162 121.5 MOLINA MCAID MOLINA MCAID 135.11 83.4 999999999 126.36 153.9 percent of total billed charges APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES) 29405_3 CDM 360 RC 29405 HCPCS outpatient 162 121.5 MOLINA MCR ADV MOLINA MCR ADV 144.18 89 999999999 126.36 153.9 percent of total billed charges APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES) 29405_3 CDM 360 RC 29405 HCPCS outpatient 162 121.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 144.18 89 999999999 126.36 153.9 percent of total billed charges APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES) 29405_3 CDM 360 RC 29405 HCPCS outpatient 162 121.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 144.18 89 999999999 126.36 153.9 percent of total billed charges APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES) 29405_3 CDM 360 RC 29405 HCPCS outpatient 162 121.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 145.8 90 999999999 126.36 153.9 percent of total billed charges APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES) 29405_3 CDM 360 RC 29405 HCPCS outpatient 162 121.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 153.9 95 999999999 126.36 153.9 percent of total billed charges APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES) 29405_3 CDM 360 RC 29405 HCPCS outpatient 162 121.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 153.9 95 999999999 126.36 153.9 percent of total billed charges APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES) 29405_3 CDM 360 RC 29405 HCPCS outpatient 162 121.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 144.18 89 999999999 126.36 153.9 percent of total billed charges APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES) 29405_3 CDM 360 RC 29405 HCPCS outpatient 162 121.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 142.56 88 999999999 126.36 153.9 percent of total billed charges APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES) 29405_3 CDM 360 RC 29405 HCPCS outpatient 162 121.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 144.18 89 999999999 126.36 153.9 percent of total billed charges APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES); WALKING OR AMBULATORY TYPE 29425_3 CDM 360 RC 29425 HCPCS outpatient 152 114 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 136.8 999999999 118.56 144.4 case rate APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES); WALKING OR AMBULATORY TYPE 29425_3 CDM 360 RC 29425 HCPCS outpatient 152 114 AETNA MCR ADV AETNA MCR ADV 118.56 78 999999999 118.56 144.4 percent of total billed charges APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES); WALKING OR AMBULATORY TYPE 29425_3 CDM 360 RC 29425 HCPCS outpatient 152 114 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 133.11 87.57 999999999 118.56 144.4 percent of total billed charges APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES); WALKING OR AMBULATORY TYPE 29425_3 CDM 360 RC 29425 HCPCS outpatient 152 114 COORDINATED CARE MCAID COORDINATED CARE MCAID 129.31 85.07 999999999 118.56 144.4 percent of total billed charges APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES); WALKING OR AMBULATORY TYPE 29425_3 CDM 360 RC 29425 HCPCS outpatient 152 114 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 129.31 85.07 999999999 118.56 144.4 percent of total billed charges APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES); WALKING OR AMBULATORY TYPE 29425_3 CDM 360 RC 29425 HCPCS outpatient 152 114 MOLINA MCAID MOLINA MCAID 126.77 83.4 999999999 118.56 144.4 percent of total billed charges APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES); WALKING OR AMBULATORY TYPE 29425_3 CDM 360 RC 29425 HCPCS outpatient 152 114 MOLINA MCR ADV MOLINA MCR ADV 135.28 89 999999999 118.56 144.4 percent of total billed charges APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES); WALKING OR AMBULATORY TYPE 29425_3 CDM 360 RC 29425 HCPCS outpatient 152 114 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 135.28 89 999999999 118.56 144.4 percent of total billed charges APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES); WALKING OR AMBULATORY TYPE 29425_3 CDM 360 RC 29425 HCPCS outpatient 152 114 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 135.28 89 999999999 118.56 144.4 percent of total billed charges APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES); WALKING OR AMBULATORY TYPE 29425_3 CDM 360 RC 29425 HCPCS outpatient 152 114 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 136.8 90 999999999 118.56 144.4 percent of total billed charges APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES); WALKING OR AMBULATORY TYPE 29425_3 CDM 360 RC 29425 HCPCS outpatient 152 114 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 144.4 95 999999999 118.56 144.4 percent of total billed charges APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES); WALKING OR AMBULATORY TYPE 29425_3 CDM 360 RC 29425 HCPCS outpatient 152 114 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 144.4 95 999999999 118.56 144.4 percent of total billed charges APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES); WALKING OR AMBULATORY TYPE 29425_3 CDM 360 RC 29425 HCPCS outpatient 152 114 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 135.28 89 999999999 118.56 144.4 percent of total billed charges APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES); WALKING OR AMBULATORY TYPE 29425_3 CDM 360 RC 29425 HCPCS outpatient 152 114 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 133.76 88 999999999 118.56 144.4 percent of total billed charges APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES); WALKING OR AMBULATORY TYPE 29425_3 CDM 360 RC 29425 HCPCS outpatient 152 114 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 135.28 89 999999999 118.56 144.4 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_1 CDM 920 RC 29505 HCPCS outpatient 153.81 115.36 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 138.43 999999999 119.97 146.12 case rate APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_1 CDM 920 RC 29505 HCPCS outpatient 153.81 115.36 AETNA MCR ADV AETNA MCR ADV 119.97 78 999999999 119.97 146.12 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_1 CDM 920 RC 29505 HCPCS outpatient 153.81 115.36 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 134.69 87.57 999999999 119.97 146.12 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_1 CDM 920 RC 29505 HCPCS outpatient 153.81 115.36 COORDINATED CARE MCAID COORDINATED CARE MCAID 130.85 85.07 999999999 119.97 146.12 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_1 CDM 920 RC 29505 HCPCS outpatient 153.81 115.36 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 130.85 85.07 999999999 119.97 146.12 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_1 CDM 920 RC 29505 HCPCS outpatient 153.81 115.36 MOLINA MCAID MOLINA MCAID 128.28 83.4 999999999 119.97 146.12 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_1 CDM 920 RC 29505 HCPCS outpatient 153.81 115.36 MOLINA MCR ADV MOLINA MCR ADV 136.89 89 999999999 119.97 146.12 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_1 CDM 920 RC 29505 HCPCS outpatient 153.81 115.36 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 136.89 89 999999999 119.97 146.12 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_1 CDM 920 RC 29505 HCPCS outpatient 153.81 115.36 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 136.89 89 999999999 119.97 146.12 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_1 CDM 920 RC 29505 HCPCS outpatient 153.81 115.36 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 138.43 90 999999999 119.97 146.12 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_1 CDM 920 RC 29505 HCPCS outpatient 153.81 115.36 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 146.12 95 999999999 119.97 146.12 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_1 CDM 920 RC 29505 HCPCS outpatient 153.81 115.36 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 146.12 95 999999999 119.97 146.12 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_1 CDM 920 RC 29505 HCPCS outpatient 153.81 115.36 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 136.89 89 999999999 119.97 146.12 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_1 CDM 920 RC 29505 HCPCS outpatient 153.81 115.36 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 135.35 88 999999999 119.97 146.12 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_1 CDM 920 RC 29505 HCPCS outpatient 153.81 115.36 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 136.89 89 999999999 119.97 146.12 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_2 CDM 920 RC 29505 HCPCS outpatient 153.81 115.36 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 138.43 999999999 119.97 146.12 case rate APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_2 CDM 920 RC 29505 HCPCS outpatient 153.81 115.36 AETNA MCR ADV AETNA MCR ADV 119.97 78 999999999 119.97 146.12 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_2 CDM 920 RC 29505 HCPCS outpatient 153.81 115.36 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 134.69 87.57 999999999 119.97 146.12 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_2 CDM 920 RC 29505 HCPCS outpatient 153.81 115.36 COORDINATED CARE MCAID COORDINATED CARE MCAID 130.85 85.07 999999999 119.97 146.12 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_2 CDM 920 RC 29505 HCPCS outpatient 153.81 115.36 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 130.85 85.07 999999999 119.97 146.12 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_2 CDM 920 RC 29505 HCPCS outpatient 153.81 115.36 MOLINA MCAID MOLINA MCAID 128.28 83.4 999999999 119.97 146.12 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_2 CDM 920 RC 29505 HCPCS outpatient 153.81 115.36 MOLINA MCR ADV MOLINA MCR ADV 136.89 89 999999999 119.97 146.12 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_2 CDM 920 RC 29505 HCPCS outpatient 153.81 115.36 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 136.89 89 999999999 119.97 146.12 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_2 CDM 920 RC 29505 HCPCS outpatient 153.81 115.36 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 136.89 89 999999999 119.97 146.12 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_2 CDM 920 RC 29505 HCPCS outpatient 153.81 115.36 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 138.43 90 999999999 119.97 146.12 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_2 CDM 920 RC 29505 HCPCS outpatient 153.81 115.36 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 146.12 95 999999999 119.97 146.12 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_2 CDM 920 RC 29505 HCPCS outpatient 153.81 115.36 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 146.12 95 999999999 119.97 146.12 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_2 CDM 920 RC 29505 HCPCS outpatient 153.81 115.36 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 136.89 89 999999999 119.97 146.12 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_2 CDM 920 RC 29505 HCPCS outpatient 153.81 115.36 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 135.35 88 999999999 119.97 146.12 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_2 CDM 920 RC 29505 HCPCS outpatient 153.81 115.36 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 136.89 89 999999999 119.97 146.12 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_3 CDM 920 RC 29505 HCPCS outpatient 196 147 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 176.4 999999999 152.88 186.2 case rate APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_3 CDM 920 RC 29505 HCPCS outpatient 196 147 AETNA MCR ADV AETNA MCR ADV 152.88 78 999999999 152.88 186.2 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_3 CDM 920 RC 29505 HCPCS outpatient 196 147 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 171.64 87.57 999999999 152.88 186.2 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_3 CDM 920 RC 29505 HCPCS outpatient 196 147 COORDINATED CARE MCAID COORDINATED CARE MCAID 166.74 85.07 999999999 152.88 186.2 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_3 CDM 920 RC 29505 HCPCS outpatient 196 147 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 166.74 85.07 999999999 152.88 186.2 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_3 CDM 920 RC 29505 HCPCS outpatient 196 147 MOLINA MCAID MOLINA MCAID 163.46 83.4 999999999 152.88 186.2 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_3 CDM 920 RC 29505 HCPCS outpatient 196 147 MOLINA MCR ADV MOLINA MCR ADV 174.44 89 999999999 152.88 186.2 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_3 CDM 920 RC 29505 HCPCS outpatient 196 147 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 174.44 89 999999999 152.88 186.2 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_3 CDM 920 RC 29505 HCPCS outpatient 196 147 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 174.44 89 999999999 152.88 186.2 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_3 CDM 920 RC 29505 HCPCS outpatient 196 147 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 176.4 90 999999999 152.88 186.2 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_3 CDM 920 RC 29505 HCPCS outpatient 196 147 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 186.2 95 999999999 152.88 186.2 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_3 CDM 920 RC 29505 HCPCS outpatient 196 147 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 186.2 95 999999999 152.88 186.2 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_3 CDM 920 RC 29505 HCPCS outpatient 196 147 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 174.44 89 999999999 152.88 186.2 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_3 CDM 920 RC 29505 HCPCS outpatient 196 147 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 172.48 88 999999999 152.88 186.2 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29505_3 CDM 920 RC 29505 HCPCS outpatient 196 147 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 174.44 89 999999999 152.88 186.2 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_1 CDM 360 RC 29515 HCPCS outpatient 147.45 110.59 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 132.71 999999999 115.01 140.08 case rate APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_1 CDM 360 RC 29515 HCPCS outpatient 147.45 110.59 AETNA MCR ADV AETNA MCR ADV 115.01 78 999999999 115.01 140.08 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_1 CDM 360 RC 29515 HCPCS outpatient 147.45 110.59 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 129.12 87.57 999999999 115.01 140.08 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_1 CDM 360 RC 29515 HCPCS outpatient 147.45 110.59 COORDINATED CARE MCAID COORDINATED CARE MCAID 125.44 85.07 999999999 115.01 140.08 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_1 CDM 360 RC 29515 HCPCS outpatient 147.45 110.59 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 125.44 85.07 999999999 115.01 140.08 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_1 CDM 360 RC 29515 HCPCS outpatient 147.45 110.59 MOLINA MCAID MOLINA MCAID 122.97 83.4 999999999 115.01 140.08 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_1 CDM 360 RC 29515 HCPCS outpatient 147.45 110.59 MOLINA MCR ADV MOLINA MCR ADV 131.23 89 999999999 115.01 140.08 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_1 CDM 360 RC 29515 HCPCS outpatient 147.45 110.59 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 131.23 89 999999999 115.01 140.08 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_1 CDM 360 RC 29515 HCPCS outpatient 147.45 110.59 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 131.23 89 999999999 115.01 140.08 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_1 CDM 360 RC 29515 HCPCS outpatient 147.45 110.59 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 132.71 90 999999999 115.01 140.08 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_1 CDM 360 RC 29515 HCPCS outpatient 147.45 110.59 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 140.08 95 999999999 115.01 140.08 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_1 CDM 360 RC 29515 HCPCS outpatient 147.45 110.59 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 140.08 95 999999999 115.01 140.08 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_1 CDM 360 RC 29515 HCPCS outpatient 147.45 110.59 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 131.23 89 999999999 115.01 140.08 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_1 CDM 360 RC 29515 HCPCS outpatient 147.45 110.59 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 129.76 88 999999999 115.01 140.08 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_1 CDM 360 RC 29515 HCPCS outpatient 147.45 110.59 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 131.23 89 999999999 115.01 140.08 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_2 CDM 360 RC 29515 HCPCS outpatient 147.45 110.59 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 132.71 999999999 115.01 140.08 case rate APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_2 CDM 360 RC 29515 HCPCS outpatient 147.45 110.59 AETNA MCR ADV AETNA MCR ADV 115.01 78 999999999 115.01 140.08 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_2 CDM 360 RC 29515 HCPCS outpatient 147.45 110.59 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 129.12 87.57 999999999 115.01 140.08 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_2 CDM 360 RC 29515 HCPCS outpatient 147.45 110.59 COORDINATED CARE MCAID COORDINATED CARE MCAID 125.44 85.07 999999999 115.01 140.08 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_2 CDM 360 RC 29515 HCPCS outpatient 147.45 110.59 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 125.44 85.07 999999999 115.01 140.08 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_2 CDM 360 RC 29515 HCPCS outpatient 147.45 110.59 MOLINA MCAID MOLINA MCAID 122.97 83.4 999999999 115.01 140.08 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_2 CDM 360 RC 29515 HCPCS outpatient 147.45 110.59 MOLINA MCR ADV MOLINA MCR ADV 131.23 89 999999999 115.01 140.08 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_2 CDM 360 RC 29515 HCPCS outpatient 147.45 110.59 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 131.23 89 999999999 115.01 140.08 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_2 CDM 360 RC 29515 HCPCS outpatient 147.45 110.59 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 131.23 89 999999999 115.01 140.08 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_2 CDM 360 RC 29515 HCPCS outpatient 147.45 110.59 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 132.71 90 999999999 115.01 140.08 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_2 CDM 360 RC 29515 HCPCS outpatient 147.45 110.59 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 140.08 95 999999999 115.01 140.08 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_2 CDM 360 RC 29515 HCPCS outpatient 147.45 110.59 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 140.08 95 999999999 115.01 140.08 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_2 CDM 360 RC 29515 HCPCS outpatient 147.45 110.59 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 131.23 89 999999999 115.01 140.08 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_2 CDM 360 RC 29515 HCPCS outpatient 147.45 110.59 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 129.76 88 999999999 115.01 140.08 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_2 CDM 360 RC 29515 HCPCS outpatient 147.45 110.59 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 131.23 89 999999999 115.01 140.08 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_3 CDM 360 RC 29515 HCPCS outpatient 142 106.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 127.8 999999999 110.76 134.9 case rate APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_3 CDM 360 RC 29515 HCPCS outpatient 142 106.5 AETNA MCR ADV AETNA MCR ADV 110.76 78 999999999 110.76 134.9 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_3 CDM 360 RC 29515 HCPCS outpatient 142 106.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 124.35 87.57 999999999 110.76 134.9 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_3 CDM 360 RC 29515 HCPCS outpatient 142 106.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 120.8 85.07 999999999 110.76 134.9 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_3 CDM 360 RC 29515 HCPCS outpatient 142 106.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 120.8 85.07 999999999 110.76 134.9 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_3 CDM 360 RC 29515 HCPCS outpatient 142 106.5 MOLINA MCAID MOLINA MCAID 118.43 83.4 999999999 110.76 134.9 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_3 CDM 360 RC 29515 HCPCS outpatient 142 106.5 MOLINA MCR ADV MOLINA MCR ADV 126.38 89 999999999 110.76 134.9 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_3 CDM 360 RC 29515 HCPCS outpatient 142 106.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 126.38 89 999999999 110.76 134.9 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_3 CDM 360 RC 29515 HCPCS outpatient 142 106.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 126.38 89 999999999 110.76 134.9 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_3 CDM 360 RC 29515 HCPCS outpatient 142 106.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 127.8 90 999999999 110.76 134.9 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_3 CDM 360 RC 29515 HCPCS outpatient 142 106.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 134.9 95 999999999 110.76 134.9 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_3 CDM 360 RC 29515 HCPCS outpatient 142 106.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 134.9 95 999999999 110.76 134.9 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_3 CDM 360 RC 29515 HCPCS outpatient 142 106.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 126.38 89 999999999 110.76 134.9 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_3 CDM 360 RC 29515 HCPCS outpatient 142 106.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 124.96 88 999999999 110.76 134.9 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29515_3 CDM 360 RC 29515 HCPCS outpatient 142 106.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 126.38 89 999999999 110.76 134.9 percent of total billed charges STRAPPING; ANKLE AND/OR FOOT 29540_1 CDM 360 RC 29540 HCPCS outpatient 53.04 39.78 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 47.74 999999999 41.37 50.39 case rate STRAPPING; ANKLE AND/OR FOOT 29540_1 CDM 360 RC 29540 HCPCS outpatient 53.04 39.78 AETNA MCR ADV AETNA MCR ADV 41.37 78 999999999 41.37 50.39 percent of total billed charges STRAPPING; ANKLE AND/OR FOOT 29540_1 CDM 360 RC 29540 HCPCS outpatient 53.04 39.78 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 46.45 87.57 999999999 41.37 50.39 percent of total billed charges STRAPPING; ANKLE AND/OR FOOT 29540_1 CDM 360 RC 29540 HCPCS outpatient 53.04 39.78 COORDINATED CARE MCAID COORDINATED CARE MCAID 45.12 85.07 999999999 41.37 50.39 percent of total billed charges STRAPPING; ANKLE AND/OR FOOT 29540_1 CDM 360 RC 29540 HCPCS outpatient 53.04 39.78 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 45.12 85.07 999999999 41.37 50.39 percent of total billed charges STRAPPING; ANKLE AND/OR FOOT 29540_1 CDM 360 RC 29540 HCPCS outpatient 53.04 39.78 MOLINA MCAID MOLINA MCAID 44.24 83.4 999999999 41.37 50.39 percent of total billed charges STRAPPING; ANKLE AND/OR FOOT 29540_1 CDM 360 RC 29540 HCPCS outpatient 53.04 39.78 MOLINA MCR ADV MOLINA MCR ADV 47.21 89 999999999 41.37 50.39 percent of total billed charges STRAPPING; ANKLE AND/OR FOOT 29540_1 CDM 360 RC 29540 HCPCS outpatient 53.04 39.78 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 47.21 89 999999999 41.37 50.39 percent of total billed charges STRAPPING; ANKLE AND/OR FOOT 29540_1 CDM 360 RC 29540 HCPCS outpatient 53.04 39.78 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 47.21 89 999999999 41.37 50.39 percent of total billed charges STRAPPING; ANKLE AND/OR FOOT 29540_1 CDM 360 RC 29540 HCPCS outpatient 53.04 39.78 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 47.74 90 999999999 41.37 50.39 percent of total billed charges STRAPPING; ANKLE AND/OR FOOT 29540_1 CDM 360 RC 29540 HCPCS outpatient 53.04 39.78 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50.39 95 999999999 41.37 50.39 percent of total billed charges STRAPPING; ANKLE AND/OR FOOT 29540_1 CDM 360 RC 29540 HCPCS outpatient 53.04 39.78 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50.39 95 999999999 41.37 50.39 percent of total billed charges STRAPPING; ANKLE AND/OR FOOT 29540_1 CDM 360 RC 29540 HCPCS outpatient 53.04 39.78 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 47.21 89 999999999 41.37 50.39 percent of total billed charges STRAPPING; ANKLE AND/OR FOOT 29540_1 CDM 360 RC 29540 HCPCS outpatient 53.04 39.78 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 46.68 88 999999999 41.37 50.39 percent of total billed charges STRAPPING; ANKLE AND/OR FOOT 29540_1 CDM 360 RC 29540 HCPCS outpatient 53.04 39.78 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 47.21 89 999999999 41.37 50.39 percent of total billed charges STRAPPING; ANKLE AND/OR FOOT 29540_3 CDM 360 RC 29540 HCPCS outpatient 56 42 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50.4 999999999 43.68 53.2 case rate STRAPPING; ANKLE AND/OR FOOT 29540_3 CDM 360 RC 29540 HCPCS outpatient 56 42 AETNA MCR ADV AETNA MCR ADV 43.68 78 999999999 43.68 53.2 percent of total billed charges STRAPPING; ANKLE AND/OR FOOT 29540_3 CDM 360 RC 29540 HCPCS outpatient 56 42 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 49.04 87.57 999999999 43.68 53.2 percent of total billed charges STRAPPING; ANKLE AND/OR FOOT 29540_3 CDM 360 RC 29540 HCPCS outpatient 56 42 COORDINATED CARE MCAID COORDINATED CARE MCAID 47.64 85.07 999999999 43.68 53.2 percent of total billed charges STRAPPING; ANKLE AND/OR FOOT 29540_3 CDM 360 RC 29540 HCPCS outpatient 56 42 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 47.64 85.07 999999999 43.68 53.2 percent of total billed charges STRAPPING; ANKLE AND/OR FOOT 29540_3 CDM 360 RC 29540 HCPCS outpatient 56 42 MOLINA MCAID MOLINA MCAID 46.7 83.4 999999999 43.68 53.2 percent of total billed charges STRAPPING; ANKLE AND/OR FOOT 29540_3 CDM 360 RC 29540 HCPCS outpatient 56 42 MOLINA MCR ADV MOLINA MCR ADV 49.84 89 999999999 43.68 53.2 percent of total billed charges STRAPPING; ANKLE AND/OR FOOT 29540_3 CDM 360 RC 29540 HCPCS outpatient 56 42 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 49.84 89 999999999 43.68 53.2 percent of total billed charges STRAPPING; ANKLE AND/OR FOOT 29540_3 CDM 360 RC 29540 HCPCS outpatient 56 42 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 49.84 89 999999999 43.68 53.2 percent of total billed charges STRAPPING; ANKLE AND/OR FOOT 29540_3 CDM 360 RC 29540 HCPCS outpatient 56 42 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50.4 90 999999999 43.68 53.2 percent of total billed charges STRAPPING; ANKLE AND/OR FOOT 29540_3 CDM 360 RC 29540 HCPCS outpatient 56 42 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 53.2 95 999999999 43.68 53.2 percent of total billed charges STRAPPING; ANKLE AND/OR FOOT 29540_3 CDM 360 RC 29540 HCPCS outpatient 56 42 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 53.2 95 999999999 43.68 53.2 percent of total billed charges STRAPPING; ANKLE AND/OR FOOT 29540_3 CDM 360 RC 29540 HCPCS outpatient 56 42 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 49.84 89 999999999 43.68 53.2 percent of total billed charges STRAPPING; ANKLE AND/OR FOOT 29540_3 CDM 360 RC 29540 HCPCS outpatient 56 42 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 49.28 88 999999999 43.68 53.2 percent of total billed charges STRAPPING; ANKLE AND/OR FOOT 29540_3 CDM 360 RC 29540 HCPCS outpatient 56 42 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 49.84 89 999999999 43.68 53.2 percent of total billed charges "REMOVAL OR BIVALVING; GAUNTLET, BOOT OR BODY CAST" 29700_3 CDM 360 RC 29700 HCPCS outpatient 124 93 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 111.6 999999999 96.72 117.8 case rate "REMOVAL OR BIVALVING; GAUNTLET, BOOT OR BODY CAST" 29700_3 CDM 360 RC 29700 HCPCS outpatient 124 93 AETNA MCR ADV AETNA MCR ADV 96.72 78 999999999 96.72 117.8 percent of total billed charges "REMOVAL OR BIVALVING; GAUNTLET, BOOT OR BODY CAST" 29700_3 CDM 360 RC 29700 HCPCS outpatient 124 93 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 108.59 87.57 999999999 96.72 117.8 percent of total billed charges "REMOVAL OR BIVALVING; GAUNTLET, BOOT OR BODY CAST" 29700_3 CDM 360 RC 29700 HCPCS outpatient 124 93 COORDINATED CARE MCAID COORDINATED CARE MCAID 105.49 85.07 999999999 96.72 117.8 percent of total billed charges "REMOVAL OR BIVALVING; GAUNTLET, BOOT OR BODY CAST" 29700_3 CDM 360 RC 29700 HCPCS outpatient 124 93 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 105.49 85.07 999999999 96.72 117.8 percent of total billed charges "REMOVAL OR BIVALVING; GAUNTLET, BOOT OR BODY CAST" 29700_3 CDM 360 RC 29700 HCPCS outpatient 124 93 MOLINA MCAID MOLINA MCAID 103.42 83.4 999999999 96.72 117.8 percent of total billed charges "REMOVAL OR BIVALVING; GAUNTLET, BOOT OR BODY CAST" 29700_3 CDM 360 RC 29700 HCPCS outpatient 124 93 MOLINA MCR ADV MOLINA MCR ADV 110.36 89 999999999 96.72 117.8 percent of total billed charges "REMOVAL OR BIVALVING; GAUNTLET, BOOT OR BODY CAST" 29700_3 CDM 360 RC 29700 HCPCS outpatient 124 93 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 110.36 89 999999999 96.72 117.8 percent of total billed charges "REMOVAL OR BIVALVING; GAUNTLET, BOOT OR BODY CAST" 29700_3 CDM 360 RC 29700 HCPCS outpatient 124 93 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 110.36 89 999999999 96.72 117.8 percent of total billed charges "REMOVAL OR BIVALVING; GAUNTLET, BOOT OR BODY CAST" 29700_3 CDM 360 RC 29700 HCPCS outpatient 124 93 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 111.6 90 999999999 96.72 117.8 percent of total billed charges "REMOVAL OR BIVALVING; GAUNTLET, BOOT OR BODY CAST" 29700_3 CDM 360 RC 29700 HCPCS outpatient 124 93 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 117.8 95 999999999 96.72 117.8 percent of total billed charges "REMOVAL OR BIVALVING; GAUNTLET, BOOT OR BODY CAST" 29700_3 CDM 360 RC 29700 HCPCS outpatient 124 93 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 117.8 95 999999999 96.72 117.8 percent of total billed charges "REMOVAL OR BIVALVING; GAUNTLET, BOOT OR BODY CAST" 29700_3 CDM 360 RC 29700 HCPCS outpatient 124 93 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 110.36 89 999999999 96.72 117.8 percent of total billed charges "REMOVAL OR BIVALVING; GAUNTLET, BOOT OR BODY CAST" 29700_3 CDM 360 RC 29700 HCPCS outpatient 124 93 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 109.12 88 999999999 96.72 117.8 percent of total billed charges "REMOVAL OR BIVALVING; GAUNTLET, BOOT OR BODY CAST" 29700_3 CDM 360 RC 29700 HCPCS outpatient 124 93 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 110.36 89 999999999 96.72 117.8 percent of total billed charges REMOVAL OR BIVALVING; FULL ARM OR FULL LEG CAST 29705_3 CDM 360 RC 29705 HCPCS outpatient 126 94.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 113.4 999999999 98.28 119.7 case rate REMOVAL OR BIVALVING; FULL ARM OR FULL LEG CAST 29705_3 CDM 360 RC 29705 HCPCS outpatient 126 94.5 AETNA MCR ADV AETNA MCR ADV 98.28 78 999999999 98.28 119.7 percent of total billed charges REMOVAL OR BIVALVING; FULL ARM OR FULL LEG CAST 29705_3 CDM 360 RC 29705 HCPCS outpatient 126 94.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 110.34 87.57 999999999 98.28 119.7 percent of total billed charges REMOVAL OR BIVALVING; FULL ARM OR FULL LEG CAST 29705_3 CDM 360 RC 29705 HCPCS outpatient 126 94.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 107.19 85.07 999999999 98.28 119.7 percent of total billed charges REMOVAL OR BIVALVING; FULL ARM OR FULL LEG CAST 29705_3 CDM 360 RC 29705 HCPCS outpatient 126 94.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 107.19 85.07 999999999 98.28 119.7 percent of total billed charges REMOVAL OR BIVALVING; FULL ARM OR FULL LEG CAST 29705_3 CDM 360 RC 29705 HCPCS outpatient 126 94.5 MOLINA MCAID MOLINA MCAID 105.08 83.4 999999999 98.28 119.7 percent of total billed charges REMOVAL OR BIVALVING; FULL ARM OR FULL LEG CAST 29705_3 CDM 360 RC 29705 HCPCS outpatient 126 94.5 MOLINA MCR ADV MOLINA MCR ADV 112.14 89 999999999 98.28 119.7 percent of total billed charges REMOVAL OR BIVALVING; FULL ARM OR FULL LEG CAST 29705_3 CDM 360 RC 29705 HCPCS outpatient 126 94.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 112.14 89 999999999 98.28 119.7 percent of total billed charges REMOVAL OR BIVALVING; FULL ARM OR FULL LEG CAST 29705_3 CDM 360 RC 29705 HCPCS outpatient 126 94.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 112.14 89 999999999 98.28 119.7 percent of total billed charges REMOVAL OR BIVALVING; FULL ARM OR FULL LEG CAST 29705_3 CDM 360 RC 29705 HCPCS outpatient 126 94.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 113.4 90 999999999 98.28 119.7 percent of total billed charges REMOVAL OR BIVALVING; FULL ARM OR FULL LEG CAST 29705_3 CDM 360 RC 29705 HCPCS outpatient 126 94.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 119.7 95 999999999 98.28 119.7 percent of total billed charges REMOVAL OR BIVALVING; FULL ARM OR FULL LEG CAST 29705_3 CDM 360 RC 29705 HCPCS outpatient 126 94.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 119.7 95 999999999 98.28 119.7 percent of total billed charges REMOVAL OR BIVALVING; FULL ARM OR FULL LEG CAST 29705_3 CDM 360 RC 29705 HCPCS outpatient 126 94.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 112.14 89 999999999 98.28 119.7 percent of total billed charges REMOVAL OR BIVALVING; FULL ARM OR FULL LEG CAST 29705_3 CDM 360 RC 29705 HCPCS outpatient 126 94.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 110.88 88 999999999 98.28 119.7 percent of total billed charges REMOVAL OR BIVALVING; FULL ARM OR FULL LEG CAST 29705_3 CDM 360 RC 29705 HCPCS outpatient 126 94.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 112.14 89 999999999 98.28 119.7 percent of total billed charges "F2 (PROTHROMBIN, COAGULATION FACTOR II) (EG, HEREDITARY HYPERCOAGULABILITY) GENE ANALYSIS, 20210G>A VARIANT" 3008124001_1 CDM 300 RC 81240 HCPCS outpatient 274 205.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 246.6 90 999999999 213.72 260.3 percent of total billed charges "F2 (PROTHROMBIN, COAGULATION FACTOR II) (EG, HEREDITARY HYPERCOAGULABILITY) GENE ANALYSIS, 20210G>A VARIANT" 3008124001_1 CDM 300 RC 81240 HCPCS outpatient 274 205.5 AETNA MCR ADV AETNA MCR ADV 213.72 78 999999999 213.72 260.3 percent of total billed charges "F2 (PROTHROMBIN, COAGULATION FACTOR II) (EG, HEREDITARY HYPERCOAGULABILITY) GENE ANALYSIS, 20210G>A VARIANT" 3008124001_1 CDM 300 RC 81240 HCPCS outpatient 274 205.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 239.94 87.57 999999999 213.72 260.3 percent of total billed charges "F2 (PROTHROMBIN, COAGULATION FACTOR II) (EG, HEREDITARY HYPERCOAGULABILITY) GENE ANALYSIS, 20210G>A VARIANT" 3008124001_1 CDM 300 RC 81240 HCPCS outpatient 274 205.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 233.09 85.07 999999999 213.72 260.3 percent of total billed charges "F2 (PROTHROMBIN, COAGULATION FACTOR II) (EG, HEREDITARY HYPERCOAGULABILITY) GENE ANALYSIS, 20210G>A VARIANT" 3008124001_1 CDM 300 RC 81240 HCPCS outpatient 274 205.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 233.09 85.07 999999999 213.72 260.3 percent of total billed charges "F2 (PROTHROMBIN, COAGULATION FACTOR II) (EG, HEREDITARY HYPERCOAGULABILITY) GENE ANALYSIS, 20210G>A VARIANT" 3008124001_1 CDM 300 RC 81240 HCPCS outpatient 274 205.5 MOLINA MCAID MOLINA MCAID 228.52 83.4 999999999 213.72 260.3 percent of total billed charges "F2 (PROTHROMBIN, COAGULATION FACTOR II) (EG, HEREDITARY HYPERCOAGULABILITY) GENE ANALYSIS, 20210G>A VARIANT" 3008124001_1 CDM 300 RC 81240 HCPCS outpatient 274 205.5 MOLINA MCR ADV MOLINA MCR ADV 243.86 89 999999999 213.72 260.3 percent of total billed charges "F2 (PROTHROMBIN, COAGULATION FACTOR II) (EG, HEREDITARY HYPERCOAGULABILITY) GENE ANALYSIS, 20210G>A VARIANT" 3008124001_1 CDM 300 RC 81240 HCPCS outpatient 274 205.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 243.86 89 999999999 213.72 260.3 percent of total billed charges "F2 (PROTHROMBIN, COAGULATION FACTOR II) (EG, HEREDITARY HYPERCOAGULABILITY) GENE ANALYSIS, 20210G>A VARIANT" 3008124001_1 CDM 300 RC 81240 HCPCS outpatient 274 205.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 243.86 89 999999999 213.72 260.3 percent of total billed charges "F2 (PROTHROMBIN, COAGULATION FACTOR II) (EG, HEREDITARY HYPERCOAGULABILITY) GENE ANALYSIS, 20210G>A VARIANT" 3008124001_1 CDM 300 RC 81240 HCPCS outpatient 274 205.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 246.6 90 999999999 213.72 260.3 percent of total billed charges "F2 (PROTHROMBIN, COAGULATION FACTOR II) (EG, HEREDITARY HYPERCOAGULABILITY) GENE ANALYSIS, 20210G>A VARIANT" 3008124001_1 CDM 300 RC 81240 HCPCS outpatient 274 205.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 260.3 95 999999999 213.72 260.3 percent of total billed charges "F2 (PROTHROMBIN, COAGULATION FACTOR II) (EG, HEREDITARY HYPERCOAGULABILITY) GENE ANALYSIS, 20210G>A VARIANT" 3008124001_1 CDM 300 RC 81240 HCPCS outpatient 274 205.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 260.3 95 999999999 213.72 260.3 percent of total billed charges "F2 (PROTHROMBIN, COAGULATION FACTOR II) (EG, HEREDITARY HYPERCOAGULABILITY) GENE ANALYSIS, 20210G>A VARIANT" 3008124001_1 CDM 300 RC 81240 HCPCS outpatient 274 205.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 243.86 89 999999999 213.72 260.3 percent of total billed charges "F2 (PROTHROMBIN, COAGULATION FACTOR II) (EG, HEREDITARY HYPERCOAGULABILITY) GENE ANALYSIS, 20210G>A VARIANT" 3008124001_1 CDM 300 RC 81240 HCPCS outpatient 274 205.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 241.12 88 999999999 213.72 260.3 percent of total billed charges "F2 (PROTHROMBIN, COAGULATION FACTOR II) (EG, HEREDITARY HYPERCOAGULABILITY) GENE ANALYSIS, 20210G>A VARIANT" 3008124001_1 CDM 300 RC 81240 HCPCS outpatient 274 205.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 243.86 89 999999999 213.72 260.3 percent of total billed charges "INFECTIOUS DISEASE, CHRONIC HEPATITIS C VIRUS (HCV) INFECTION, SIX BIOCHEMICAL ASSAYS (ALT, A2-MACROGLOBULIN, APOLIPOPROTEIN A-1, TOTAL BILIRUBIN, GGT, AND HAPTOGLOBIN) UTILIZING SERUM, PROGNOSTIC ALGORITHM REPORTED AS SCORES FOR FIBROSIS AND NECROINFLAMMATORY ACTIVITY IN LIVER" 3008159602_1 CDM 300 RC 81596 HCPCS outpatient 325 243.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 292.5 90 999999999 253.5 308.75 percent of total billed charges "INFECTIOUS DISEASE, CHRONIC HEPATITIS C VIRUS (HCV) INFECTION, SIX BIOCHEMICAL ASSAYS (ALT, A2-MACROGLOBULIN, APOLIPOPROTEIN A-1, TOTAL BILIRUBIN, GGT, AND HAPTOGLOBIN) UTILIZING SERUM, PROGNOSTIC ALGORITHM REPORTED AS SCORES FOR FIBROSIS AND NECROINFLAMMATORY ACTIVITY IN LIVER" 3008159602_1 CDM 300 RC 81596 HCPCS outpatient 325 243.75 AETNA MCR ADV AETNA MCR ADV 253.5 78 999999999 253.5 308.75 percent of total billed charges "INFECTIOUS DISEASE, CHRONIC HEPATITIS C VIRUS (HCV) INFECTION, SIX BIOCHEMICAL ASSAYS (ALT, A2-MACROGLOBULIN, APOLIPOPROTEIN A-1, TOTAL BILIRUBIN, GGT, AND HAPTOGLOBIN) UTILIZING SERUM, PROGNOSTIC ALGORITHM REPORTED AS SCORES FOR FIBROSIS AND NECROINFLAMMATORY ACTIVITY IN LIVER" 3008159602_1 CDM 300 RC 81596 HCPCS outpatient 325 243.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 284.6 87.57 999999999 253.5 308.75 percent of total billed charges "INFECTIOUS DISEASE, CHRONIC HEPATITIS C VIRUS (HCV) INFECTION, SIX BIOCHEMICAL ASSAYS (ALT, A2-MACROGLOBULIN, APOLIPOPROTEIN A-1, TOTAL BILIRUBIN, GGT, AND HAPTOGLOBIN) UTILIZING SERUM, PROGNOSTIC ALGORITHM REPORTED AS SCORES FOR FIBROSIS AND NECROINFLAMMATORY ACTIVITY IN LIVER" 3008159602_1 CDM 300 RC 81596 HCPCS outpatient 325 243.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 276.48 85.07 999999999 253.5 308.75 percent of total billed charges "INFECTIOUS DISEASE, CHRONIC HEPATITIS C VIRUS (HCV) INFECTION, SIX BIOCHEMICAL ASSAYS (ALT, A2-MACROGLOBULIN, APOLIPOPROTEIN A-1, TOTAL BILIRUBIN, GGT, AND HAPTOGLOBIN) UTILIZING SERUM, PROGNOSTIC ALGORITHM REPORTED AS SCORES FOR FIBROSIS AND NECROINFLAMMATORY ACTIVITY IN LIVER" 3008159602_1 CDM 300 RC 81596 HCPCS outpatient 325 243.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 276.48 85.07 999999999 253.5 308.75 percent of total billed charges "INFECTIOUS DISEASE, CHRONIC HEPATITIS C VIRUS (HCV) INFECTION, SIX BIOCHEMICAL ASSAYS (ALT, A2-MACROGLOBULIN, APOLIPOPROTEIN A-1, TOTAL BILIRUBIN, GGT, AND HAPTOGLOBIN) UTILIZING SERUM, PROGNOSTIC ALGORITHM REPORTED AS SCORES FOR FIBROSIS AND NECROINFLAMMATORY ACTIVITY IN LIVER" 3008159602_1 CDM 300 RC 81596 HCPCS outpatient 325 243.75 MOLINA MCAID MOLINA MCAID 271.05 83.4 999999999 253.5 308.75 percent of total billed charges "INFECTIOUS DISEASE, CHRONIC HEPATITIS C VIRUS (HCV) INFECTION, SIX BIOCHEMICAL ASSAYS (ALT, A2-MACROGLOBULIN, APOLIPOPROTEIN A-1, TOTAL BILIRUBIN, GGT, AND HAPTOGLOBIN) UTILIZING SERUM, PROGNOSTIC ALGORITHM REPORTED AS SCORES FOR FIBROSIS AND NECROINFLAMMATORY ACTIVITY IN LIVER" 3008159602_1 CDM 300 RC 81596 HCPCS outpatient 325 243.75 MOLINA MCR ADV MOLINA MCR ADV 289.25 89 999999999 253.5 308.75 percent of total billed charges "INFECTIOUS DISEASE, CHRONIC HEPATITIS C VIRUS (HCV) INFECTION, SIX BIOCHEMICAL ASSAYS (ALT, A2-MACROGLOBULIN, APOLIPOPROTEIN A-1, TOTAL BILIRUBIN, GGT, AND HAPTOGLOBIN) UTILIZING SERUM, PROGNOSTIC ALGORITHM REPORTED AS SCORES FOR FIBROSIS AND NECROINFLAMMATORY ACTIVITY IN LIVER" 3008159602_1 CDM 300 RC 81596 HCPCS outpatient 325 243.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 289.25 89 999999999 253.5 308.75 percent of total billed charges "INFECTIOUS DISEASE, CHRONIC HEPATITIS C VIRUS (HCV) INFECTION, SIX BIOCHEMICAL ASSAYS (ALT, A2-MACROGLOBULIN, APOLIPOPROTEIN A-1, TOTAL BILIRUBIN, GGT, AND HAPTOGLOBIN) UTILIZING SERUM, PROGNOSTIC ALGORITHM REPORTED AS SCORES FOR FIBROSIS AND NECROINFLAMMATORY ACTIVITY IN LIVER" 3008159602_1 CDM 300 RC 81596 HCPCS outpatient 325 243.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 289.25 89 999999999 253.5 308.75 percent of total billed charges "INFECTIOUS DISEASE, CHRONIC HEPATITIS C VIRUS (HCV) INFECTION, SIX BIOCHEMICAL ASSAYS (ALT, A2-MACROGLOBULIN, APOLIPOPROTEIN A-1, TOTAL BILIRUBIN, GGT, AND HAPTOGLOBIN) UTILIZING SERUM, PROGNOSTIC ALGORITHM REPORTED AS SCORES FOR FIBROSIS AND NECROINFLAMMATORY ACTIVITY IN LIVER" 3008159602_1 CDM 300 RC 81596 HCPCS outpatient 325 243.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 292.5 90 999999999 253.5 308.75 percent of total billed charges "INFECTIOUS DISEASE, CHRONIC HEPATITIS C VIRUS (HCV) INFECTION, SIX BIOCHEMICAL ASSAYS (ALT, A2-MACROGLOBULIN, APOLIPOPROTEIN A-1, TOTAL BILIRUBIN, GGT, AND HAPTOGLOBIN) UTILIZING SERUM, PROGNOSTIC ALGORITHM REPORTED AS SCORES FOR FIBROSIS AND NECROINFLAMMATORY ACTIVITY IN LIVER" 3008159602_1 CDM 300 RC 81596 HCPCS outpatient 325 243.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 308.75 95 999999999 253.5 308.75 percent of total billed charges "INFECTIOUS DISEASE, CHRONIC HEPATITIS C VIRUS (HCV) INFECTION, SIX BIOCHEMICAL ASSAYS (ALT, A2-MACROGLOBULIN, APOLIPOPROTEIN A-1, TOTAL BILIRUBIN, GGT, AND HAPTOGLOBIN) UTILIZING SERUM, PROGNOSTIC ALGORITHM REPORTED AS SCORES FOR FIBROSIS AND NECROINFLAMMATORY ACTIVITY IN LIVER" 3008159602_1 CDM 300 RC 81596 HCPCS outpatient 325 243.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 308.75 95 999999999 253.5 308.75 percent of total billed charges "INFECTIOUS DISEASE, CHRONIC HEPATITIS C VIRUS (HCV) INFECTION, SIX BIOCHEMICAL ASSAYS (ALT, A2-MACROGLOBULIN, APOLIPOPROTEIN A-1, TOTAL BILIRUBIN, GGT, AND HAPTOGLOBIN) UTILIZING SERUM, PROGNOSTIC ALGORITHM REPORTED AS SCORES FOR FIBROSIS AND NECROINFLAMMATORY ACTIVITY IN LIVER" 3008159602_1 CDM 300 RC 81596 HCPCS outpatient 325 243.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 289.25 89 999999999 253.5 308.75 percent of total billed charges "INFECTIOUS DISEASE, CHRONIC HEPATITIS C VIRUS (HCV) INFECTION, SIX BIOCHEMICAL ASSAYS (ALT, A2-MACROGLOBULIN, APOLIPOPROTEIN A-1, TOTAL BILIRUBIN, GGT, AND HAPTOGLOBIN) UTILIZING SERUM, PROGNOSTIC ALGORITHM REPORTED AS SCORES FOR FIBROSIS AND NECROINFLAMMATORY ACTIVITY IN LIVER" 3008159602_1 CDM 300 RC 81596 HCPCS outpatient 325 243.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 286 88 999999999 253.5 308.75 percent of total billed charges "INFECTIOUS DISEASE, CHRONIC HEPATITIS C VIRUS (HCV) INFECTION, SIX BIOCHEMICAL ASSAYS (ALT, A2-MACROGLOBULIN, APOLIPOPROTEIN A-1, TOTAL BILIRUBIN, GGT, AND HAPTOGLOBIN) UTILIZING SERUM, PROGNOSTIC ALGORITHM REPORTED AS SCORES FOR FIBROSIS AND NECROINFLAMMATORY ACTIVITY IN LIVER" 3008159602_1 CDM 300 RC 81596 HCPCS outpatient 325 243.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 289.25 89 999999999 253.5 308.75 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; OTHER SOURCES" 3008227101_1 CDM 300 RC 82271 HCPCS outpatient 48 36 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 43.2 90 999999999 37.44 45.6 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; OTHER SOURCES" 3008227101_1 CDM 300 RC 82271 HCPCS outpatient 48 36 AETNA MCR ADV AETNA MCR ADV 37.44 78 999999999 37.44 45.6 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; OTHER SOURCES" 3008227101_1 CDM 300 RC 82271 HCPCS outpatient 48 36 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 42.03 87.57 999999999 37.44 45.6 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; OTHER SOURCES" 3008227101_1 CDM 300 RC 82271 HCPCS outpatient 48 36 COORDINATED CARE MCAID COORDINATED CARE MCAID 40.83 85.07 999999999 37.44 45.6 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; OTHER SOURCES" 3008227101_1 CDM 300 RC 82271 HCPCS outpatient 48 36 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 40.83 85.07 999999999 37.44 45.6 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; OTHER SOURCES" 3008227101_1 CDM 300 RC 82271 HCPCS outpatient 48 36 MOLINA MCAID MOLINA MCAID 40.03 83.4 999999999 37.44 45.6 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; OTHER SOURCES" 3008227101_1 CDM 300 RC 82271 HCPCS outpatient 48 36 MOLINA MCR ADV MOLINA MCR ADV 42.72 89 999999999 37.44 45.6 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; OTHER SOURCES" 3008227101_1 CDM 300 RC 82271 HCPCS outpatient 48 36 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 42.72 89 999999999 37.44 45.6 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; OTHER SOURCES" 3008227101_1 CDM 300 RC 82271 HCPCS outpatient 48 36 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 42.72 89 999999999 37.44 45.6 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; OTHER SOURCES" 3008227101_1 CDM 300 RC 82271 HCPCS outpatient 48 36 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 43.2 90 999999999 37.44 45.6 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; OTHER SOURCES" 3008227101_1 CDM 300 RC 82271 HCPCS outpatient 48 36 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 45.6 95 999999999 37.44 45.6 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; OTHER SOURCES" 3008227101_1 CDM 300 RC 82271 HCPCS outpatient 48 36 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 45.6 95 999999999 37.44 45.6 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; OTHER SOURCES" 3008227101_1 CDM 300 RC 82271 HCPCS outpatient 48 36 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 42.72 89 999999999 37.44 45.6 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; OTHER SOURCES" 3008227101_1 CDM 300 RC 82271 HCPCS outpatient 48 36 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 42.24 88 999999999 37.44 45.6 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; OTHER SOURCES" 3008227101_1 CDM 300 RC 82271 HCPCS outpatient 48 36 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 42.72 89 999999999 37.44 45.6 percent of total billed charges "CELL COUNT, MISCELLANEOUS BODY FLUIDS (EG, CEREBROSPINAL FLUID, JOINT FLUID), EXCEPT BLOOD; WITH DIFFERENTIAL COUNT" 3008905101_1 CDM 300 RC 89051 HCPCS outpatient 115 86.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 103.5 90 999999999 89.7 109.25 percent of total billed charges "CELL COUNT, MISCELLANEOUS BODY FLUIDS (EG, CEREBROSPINAL FLUID, JOINT FLUID), EXCEPT BLOOD; WITH DIFFERENTIAL COUNT" 3008905101_1 CDM 300 RC 89051 HCPCS outpatient 115 86.25 AETNA MCR ADV AETNA MCR ADV 89.7 78 999999999 89.7 109.25 percent of total billed charges "CELL COUNT, MISCELLANEOUS BODY FLUIDS (EG, CEREBROSPINAL FLUID, JOINT FLUID), EXCEPT BLOOD; WITH DIFFERENTIAL COUNT" 3008905101_1 CDM 300 RC 89051 HCPCS outpatient 115 86.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 100.71 87.57 999999999 89.7 109.25 percent of total billed charges "CELL COUNT, MISCELLANEOUS BODY FLUIDS (EG, CEREBROSPINAL FLUID, JOINT FLUID), EXCEPT BLOOD; WITH DIFFERENTIAL COUNT" 3008905101_1 CDM 300 RC 89051 HCPCS outpatient 115 86.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 97.83 85.07 999999999 89.7 109.25 percent of total billed charges "CELL COUNT, MISCELLANEOUS BODY FLUIDS (EG, CEREBROSPINAL FLUID, JOINT FLUID), EXCEPT BLOOD; WITH DIFFERENTIAL COUNT" 3008905101_1 CDM 300 RC 89051 HCPCS outpatient 115 86.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 97.83 85.07 999999999 89.7 109.25 percent of total billed charges "CELL COUNT, MISCELLANEOUS BODY FLUIDS (EG, CEREBROSPINAL FLUID, JOINT FLUID), EXCEPT BLOOD; WITH DIFFERENTIAL COUNT" 3008905101_1 CDM 300 RC 89051 HCPCS outpatient 115 86.25 MOLINA MCAID MOLINA MCAID 95.91 83.4 999999999 89.7 109.25 percent of total billed charges "CELL COUNT, MISCELLANEOUS BODY FLUIDS (EG, CEREBROSPINAL FLUID, JOINT FLUID), EXCEPT BLOOD; WITH DIFFERENTIAL COUNT" 3008905101_1 CDM 300 RC 89051 HCPCS outpatient 115 86.25 MOLINA MCR ADV MOLINA MCR ADV 102.35 89 999999999 89.7 109.25 percent of total billed charges "CELL COUNT, MISCELLANEOUS BODY FLUIDS (EG, CEREBROSPINAL FLUID, JOINT FLUID), EXCEPT BLOOD; WITH DIFFERENTIAL COUNT" 3008905101_1 CDM 300 RC 89051 HCPCS outpatient 115 86.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 102.35 89 999999999 89.7 109.25 percent of total billed charges "CELL COUNT, MISCELLANEOUS BODY FLUIDS (EG, CEREBROSPINAL FLUID, JOINT FLUID), EXCEPT BLOOD; WITH DIFFERENTIAL COUNT" 3008905101_1 CDM 300 RC 89051 HCPCS outpatient 115 86.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 102.35 89 999999999 89.7 109.25 percent of total billed charges "CELL COUNT, MISCELLANEOUS BODY FLUIDS (EG, CEREBROSPINAL FLUID, JOINT FLUID), EXCEPT BLOOD; WITH DIFFERENTIAL COUNT" 3008905101_1 CDM 300 RC 89051 HCPCS outpatient 115 86.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 103.5 90 999999999 89.7 109.25 percent of total billed charges "CELL COUNT, MISCELLANEOUS BODY FLUIDS (EG, CEREBROSPINAL FLUID, JOINT FLUID), EXCEPT BLOOD; WITH DIFFERENTIAL COUNT" 3008905101_1 CDM 300 RC 89051 HCPCS outpatient 115 86.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 109.25 95 999999999 89.7 109.25 percent of total billed charges "CELL COUNT, MISCELLANEOUS BODY FLUIDS (EG, CEREBROSPINAL FLUID, JOINT FLUID), EXCEPT BLOOD; WITH DIFFERENTIAL COUNT" 3008905101_1 CDM 300 RC 89051 HCPCS outpatient 115 86.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 109.25 95 999999999 89.7 109.25 percent of total billed charges "CELL COUNT, MISCELLANEOUS BODY FLUIDS (EG, CEREBROSPINAL FLUID, JOINT FLUID), EXCEPT BLOOD; WITH DIFFERENTIAL COUNT" 3008905101_1 CDM 300 RC 89051 HCPCS outpatient 115 86.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 102.35 89 999999999 89.7 109.25 percent of total billed charges "CELL COUNT, MISCELLANEOUS BODY FLUIDS (EG, CEREBROSPINAL FLUID, JOINT FLUID), EXCEPT BLOOD; WITH DIFFERENTIAL COUNT" 3008905101_1 CDM 300 RC 89051 HCPCS outpatient 115 86.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 101.2 88 999999999 89.7 109.25 percent of total billed charges "CELL COUNT, MISCELLANEOUS BODY FLUIDS (EG, CEREBROSPINAL FLUID, JOINT FLUID), EXCEPT BLOOD; WITH DIFFERENTIAL COUNT" 3008905101_1 CDM 300 RC 89051 HCPCS outpatient 115 86.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 102.35 89 999999999 89.7 109.25 percent of total billed charges "CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT POLARIZING LENS ANALYSIS, TISSUE OR ANY BODY FLUID (EXCEPT URINE)" 3008906001_1 CDM 300 RC 89060 HCPCS outpatient 82 61.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 73.8 90 999999999 63.96 77.9 percent of total billed charges "CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT POLARIZING LENS ANALYSIS, TISSUE OR ANY BODY FLUID (EXCEPT URINE)" 3008906001_1 CDM 300 RC 89060 HCPCS outpatient 82 61.5 AETNA MCR ADV AETNA MCR ADV 63.96 78 999999999 63.96 77.9 percent of total billed charges "CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT POLARIZING LENS ANALYSIS, TISSUE OR ANY BODY FLUID (EXCEPT URINE)" 3008906001_1 CDM 300 RC 89060 HCPCS outpatient 82 61.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 71.81 87.57 999999999 63.96 77.9 percent of total billed charges "CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT POLARIZING LENS ANALYSIS, TISSUE OR ANY BODY FLUID (EXCEPT URINE)" 3008906001_1 CDM 300 RC 89060 HCPCS outpatient 82 61.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 69.76 85.07 999999999 63.96 77.9 percent of total billed charges "CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT POLARIZING LENS ANALYSIS, TISSUE OR ANY BODY FLUID (EXCEPT URINE)" 3008906001_1 CDM 300 RC 89060 HCPCS outpatient 82 61.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 69.76 85.07 999999999 63.96 77.9 percent of total billed charges "CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT POLARIZING LENS ANALYSIS, TISSUE OR ANY BODY FLUID (EXCEPT URINE)" 3008906001_1 CDM 300 RC 89060 HCPCS outpatient 82 61.5 MOLINA MCAID MOLINA MCAID 68.39 83.4 999999999 63.96 77.9 percent of total billed charges "CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT POLARIZING LENS ANALYSIS, TISSUE OR ANY BODY FLUID (EXCEPT URINE)" 3008906001_1 CDM 300 RC 89060 HCPCS outpatient 82 61.5 MOLINA MCR ADV MOLINA MCR ADV 72.98 89 999999999 63.96 77.9 percent of total billed charges "CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT POLARIZING LENS ANALYSIS, TISSUE OR ANY BODY FLUID (EXCEPT URINE)" 3008906001_1 CDM 300 RC 89060 HCPCS outpatient 82 61.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 72.98 89 999999999 63.96 77.9 percent of total billed charges "CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT POLARIZING LENS ANALYSIS, TISSUE OR ANY BODY FLUID (EXCEPT URINE)" 3008906001_1 CDM 300 RC 89060 HCPCS outpatient 82 61.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 72.98 89 999999999 63.96 77.9 percent of total billed charges "CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT POLARIZING LENS ANALYSIS, TISSUE OR ANY BODY FLUID (EXCEPT URINE)" 3008906001_1 CDM 300 RC 89060 HCPCS outpatient 82 61.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 73.8 90 999999999 63.96 77.9 percent of total billed charges "CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT POLARIZING LENS ANALYSIS, TISSUE OR ANY BODY FLUID (EXCEPT URINE)" 3008906001_1 CDM 300 RC 89060 HCPCS outpatient 82 61.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 77.9 95 999999999 63.96 77.9 percent of total billed charges "CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT POLARIZING LENS ANALYSIS, TISSUE OR ANY BODY FLUID (EXCEPT URINE)" 3008906001_1 CDM 300 RC 89060 HCPCS outpatient 82 61.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 77.9 95 999999999 63.96 77.9 percent of total billed charges "CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT POLARIZING LENS ANALYSIS, TISSUE OR ANY BODY FLUID (EXCEPT URINE)" 3008906001_1 CDM 300 RC 89060 HCPCS outpatient 82 61.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 72.98 89 999999999 63.96 77.9 percent of total billed charges "CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT POLARIZING LENS ANALYSIS, TISSUE OR ANY BODY FLUID (EXCEPT URINE)" 3008906001_1 CDM 300 RC 89060 HCPCS outpatient 82 61.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 72.16 88 999999999 63.96 77.9 percent of total billed charges "CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT POLARIZING LENS ANALYSIS, TISSUE OR ANY BODY FLUID (EXCEPT URINE)" 3008906001_1 CDM 300 RC 89060 HCPCS outpatient 82 61.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 72.98 89 999999999 63.96 77.9 percent of total billed charges HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE PATIENT IN OTHER THAN AN OFFICE TO A LABORATORY (DISTANCE MAY BE INDICATED) 3009900101_1 CDM 300 RC 99001 HCPCS outpatient 50 37.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 45 90 999999999 39 47.5 percent of total billed charges HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE PATIENT IN OTHER THAN AN OFFICE TO A LABORATORY (DISTANCE MAY BE INDICATED) 3009900101_1 CDM 300 RC 99001 HCPCS outpatient 50 37.5 AETNA MCR ADV AETNA MCR ADV 39 78 999999999 39 47.5 percent of total billed charges HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE PATIENT IN OTHER THAN AN OFFICE TO A LABORATORY (DISTANCE MAY BE INDICATED) 3009900101_1 CDM 300 RC 99001 HCPCS outpatient 50 37.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 43.79 87.57 999999999 39 47.5 percent of total billed charges HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE PATIENT IN OTHER THAN AN OFFICE TO A LABORATORY (DISTANCE MAY BE INDICATED) 3009900101_1 CDM 300 RC 99001 HCPCS outpatient 50 37.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 42.54 85.07 999999999 39 47.5 percent of total billed charges HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE PATIENT IN OTHER THAN AN OFFICE TO A LABORATORY (DISTANCE MAY BE INDICATED) 3009900101_1 CDM 300 RC 99001 HCPCS outpatient 50 37.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 42.54 85.07 999999999 39 47.5 percent of total billed charges HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE PATIENT IN OTHER THAN AN OFFICE TO A LABORATORY (DISTANCE MAY BE INDICATED) 3009900101_1 CDM 300 RC 99001 HCPCS outpatient 50 37.5 MOLINA MCAID MOLINA MCAID 41.7 83.4 999999999 39 47.5 percent of total billed charges HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE PATIENT IN OTHER THAN AN OFFICE TO A LABORATORY (DISTANCE MAY BE INDICATED) 3009900101_1 CDM 300 RC 99001 HCPCS outpatient 50 37.5 MOLINA MCR ADV MOLINA MCR ADV 44.5 89 999999999 39 47.5 percent of total billed charges HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE PATIENT IN OTHER THAN AN OFFICE TO A LABORATORY (DISTANCE MAY BE INDICATED) 3009900101_1 CDM 300 RC 99001 HCPCS outpatient 50 37.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 44.5 89 999999999 39 47.5 percent of total billed charges HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE PATIENT IN OTHER THAN AN OFFICE TO A LABORATORY (DISTANCE MAY BE INDICATED) 3009900101_1 CDM 300 RC 99001 HCPCS outpatient 50 37.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 44.5 89 999999999 39 47.5 percent of total billed charges HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE PATIENT IN OTHER THAN AN OFFICE TO A LABORATORY (DISTANCE MAY BE INDICATED) 3009900101_1 CDM 300 RC 99001 HCPCS outpatient 50 37.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 45 90 999999999 39 47.5 percent of total billed charges HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE PATIENT IN OTHER THAN AN OFFICE TO A LABORATORY (DISTANCE MAY BE INDICATED) 3009900101_1 CDM 300 RC 99001 HCPCS outpatient 50 37.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 47.5 95 999999999 39 47.5 percent of total billed charges HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE PATIENT IN OTHER THAN AN OFFICE TO A LABORATORY (DISTANCE MAY BE INDICATED) 3009900101_1 CDM 300 RC 99001 HCPCS outpatient 50 37.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 47.5 95 999999999 39 47.5 percent of total billed charges HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE PATIENT IN OTHER THAN AN OFFICE TO A LABORATORY (DISTANCE MAY BE INDICATED) 3009900101_1 CDM 300 RC 99001 HCPCS outpatient 50 37.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 44.5 89 999999999 39 47.5 percent of total billed charges HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE PATIENT IN OTHER THAN AN OFFICE TO A LABORATORY (DISTANCE MAY BE INDICATED) 3009900101_1 CDM 300 RC 99001 HCPCS outpatient 50 37.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 44 88 999999999 39 47.5 percent of total billed charges HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE PATIENT IN OTHER THAN AN OFFICE TO A LABORATORY (DISTANCE MAY BE INDICATED) 3009900101_1 CDM 300 RC 99001 HCPCS outpatient 50 37.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 44.5 89 999999999 39 47.5 percent of total billed charges HC HOSPITAL OUTPATIENT CLINIC VISIT COVID-19 SPECIMEN COLLECTION 300C980301_1 CDM 300 RC NONE HCPCS outpatient 37 27.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 33.3 90 999999999 28.86 35.15 percent of total billed charges HC HOSPITAL OUTPATIENT CLINIC VISIT COVID-19 SPECIMEN COLLECTION 300C980301_1 CDM 300 RC NONE HCPCS outpatient 37 27.75 AETNA MCR ADV AETNA MCR ADV 28.86 78 999999999 28.86 35.15 percent of total billed charges HC HOSPITAL OUTPATIENT CLINIC VISIT COVID-19 SPECIMEN COLLECTION 300C980301_1 CDM 300 RC NONE HCPCS outpatient 37 27.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 32.4 87.57 999999999 28.86 35.15 percent of total billed charges HC HOSPITAL OUTPATIENT CLINIC VISIT COVID-19 SPECIMEN COLLECTION 300C980301_1 CDM 300 RC NONE HCPCS outpatient 37 27.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 31.48 85.07 999999999 28.86 35.15 percent of total billed charges HC HOSPITAL OUTPATIENT CLINIC VISIT COVID-19 SPECIMEN COLLECTION 300C980301_1 CDM 300 RC NONE HCPCS outpatient 37 27.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 31.48 85.07 999999999 28.86 35.15 percent of total billed charges HC HOSPITAL OUTPATIENT CLINIC VISIT COVID-19 SPECIMEN COLLECTION 300C980301_1 CDM 300 RC NONE HCPCS outpatient 37 27.75 MOLINA MCAID MOLINA MCAID 30.86 83.4 999999999 28.86 35.15 percent of total billed charges HC HOSPITAL OUTPATIENT CLINIC VISIT COVID-19 SPECIMEN COLLECTION 300C980301_1 CDM 300 RC NONE HCPCS outpatient 37 27.75 MOLINA MCR ADV MOLINA MCR ADV 32.93 89 999999999 28.86 35.15 percent of total billed charges HC HOSPITAL OUTPATIENT CLINIC VISIT COVID-19 SPECIMEN COLLECTION 300C980301_1 CDM 300 RC NONE HCPCS outpatient 37 27.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 32.93 89 999999999 28.86 35.15 percent of total billed charges HC HOSPITAL OUTPATIENT CLINIC VISIT COVID-19 SPECIMEN COLLECTION 300C980301_1 CDM 300 RC NONE HCPCS outpatient 37 27.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 32.93 89 999999999 28.86 35.15 percent of total billed charges HC HOSPITAL OUTPATIENT CLINIC VISIT COVID-19 SPECIMEN COLLECTION 300C980301_1 CDM 300 RC NONE HCPCS outpatient 37 27.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 33.3 90 999999999 28.86 35.15 percent of total billed charges HC HOSPITAL OUTPATIENT CLINIC VISIT COVID-19 SPECIMEN COLLECTION 300C980301_1 CDM 300 RC NONE HCPCS outpatient 37 27.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 35.15 95 999999999 28.86 35.15 percent of total billed charges HC HOSPITAL OUTPATIENT CLINIC VISIT COVID-19 SPECIMEN COLLECTION 300C980301_1 CDM 300 RC NONE HCPCS outpatient 37 27.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 35.15 95 999999999 28.86 35.15 percent of total billed charges HC HOSPITAL OUTPATIENT CLINIC VISIT COVID-19 SPECIMEN COLLECTION 300C980301_1 CDM 300 RC NONE HCPCS outpatient 37 27.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 32.93 89 999999999 28.86 35.15 percent of total billed charges HC HOSPITAL OUTPATIENT CLINIC VISIT COVID-19 SPECIMEN COLLECTION 300C980301_1 CDM 300 RC NONE HCPCS outpatient 37 27.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 32.56 88 999999999 28.86 35.15 percent of total billed charges HC HOSPITAL OUTPATIENT CLINIC VISIT COVID-19 SPECIMEN COLLECTION 300C980301_1 CDM 300 RC NONE HCPCS outpatient 37 27.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 32.93 89 999999999 28.86 35.15 percent of total billed charges ALCOHOL AND/OR DRUG ASSESSMENT 300H000101_1 CDM 300 RC H0001 HCPCS outpatient 82 61.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 73.8 90 999999999 63.96 77.9 percent of total billed charges ALCOHOL AND/OR DRUG ASSESSMENT 300H000101_1 CDM 300 RC H0001 HCPCS outpatient 82 61.5 AETNA MCR ADV AETNA MCR ADV 63.96 78 999999999 63.96 77.9 percent of total billed charges ALCOHOL AND/OR DRUG ASSESSMENT 300H000101_1 CDM 300 RC H0001 HCPCS outpatient 82 61.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 71.81 87.57 999999999 63.96 77.9 percent of total billed charges ALCOHOL AND/OR DRUG ASSESSMENT 300H000101_1 CDM 300 RC H0001 HCPCS outpatient 82 61.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 69.76 85.07 999999999 63.96 77.9 percent of total billed charges ALCOHOL AND/OR DRUG ASSESSMENT 300H000101_1 CDM 300 RC H0001 HCPCS outpatient 82 61.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 69.76 85.07 999999999 63.96 77.9 percent of total billed charges ALCOHOL AND/OR DRUG ASSESSMENT 300H000101_1 CDM 300 RC H0001 HCPCS outpatient 82 61.5 MOLINA MCAID MOLINA MCAID 68.39 83.4 999999999 63.96 77.9 percent of total billed charges ALCOHOL AND/OR DRUG ASSESSMENT 300H000101_1 CDM 300 RC H0001 HCPCS outpatient 82 61.5 MOLINA MCR ADV MOLINA MCR ADV 72.98 89 999999999 63.96 77.9 percent of total billed charges ALCOHOL AND/OR DRUG ASSESSMENT 300H000101_1 CDM 300 RC H0001 HCPCS outpatient 82 61.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 72.98 89 999999999 63.96 77.9 percent of total billed charges ALCOHOL AND/OR DRUG ASSESSMENT 300H000101_1 CDM 300 RC H0001 HCPCS outpatient 82 61.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 72.98 89 999999999 63.96 77.9 percent of total billed charges ALCOHOL AND/OR DRUG ASSESSMENT 300H000101_1 CDM 300 RC H0001 HCPCS outpatient 82 61.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 73.8 90 999999999 63.96 77.9 percent of total billed charges ALCOHOL AND/OR DRUG ASSESSMENT 300H000101_1 CDM 300 RC H0001 HCPCS outpatient 82 61.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 77.9 95 999999999 63.96 77.9 percent of total billed charges ALCOHOL AND/OR DRUG ASSESSMENT 300H000101_1 CDM 300 RC H0001 HCPCS outpatient 82 61.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 77.9 95 999999999 63.96 77.9 percent of total billed charges ALCOHOL AND/OR DRUG ASSESSMENT 300H000101_1 CDM 300 RC H0001 HCPCS outpatient 82 61.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 72.98 89 999999999 63.96 77.9 percent of total billed charges ALCOHOL AND/OR DRUG ASSESSMENT 300H000101_1 CDM 300 RC H0001 HCPCS outpatient 82 61.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 72.16 88 999999999 63.96 77.9 percent of total billed charges ALCOHOL AND/OR DRUG ASSESSMENT 300H000101_1 CDM 300 RC H0001 HCPCS outpatient 82 61.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 72.98 89 999999999 63.96 77.9 percent of total billed charges "BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520)" 3018004801_1 CDM 301 RC 80048 HCPCS outpatient 138 103.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 124.2 90 999999999 107.64 131.1 percent of total billed charges "BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520)" 3018004801_1 CDM 301 RC 80048 HCPCS outpatient 138 103.5 AETNA MCR ADV AETNA MCR ADV 107.64 78 999999999 107.64 131.1 percent of total billed charges "BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520)" 3018004801_1 CDM 301 RC 80048 HCPCS outpatient 138 103.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 120.85 87.57 999999999 107.64 131.1 percent of total billed charges "BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520)" 3018004801_1 CDM 301 RC 80048 HCPCS outpatient 138 103.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 117.4 85.07 999999999 107.64 131.1 percent of total billed charges "BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520)" 3018004801_1 CDM 301 RC 80048 HCPCS outpatient 138 103.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 117.4 85.07 999999999 107.64 131.1 percent of total billed charges "BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520)" 3018004801_1 CDM 301 RC 80048 HCPCS outpatient 138 103.5 MOLINA MCAID MOLINA MCAID 115.09 83.4 999999999 107.64 131.1 percent of total billed charges "BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520)" 3018004801_1 CDM 301 RC 80048 HCPCS outpatient 138 103.5 MOLINA MCR ADV MOLINA MCR ADV 122.82 89 999999999 107.64 131.1 percent of total billed charges "BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520)" 3018004801_1 CDM 301 RC 80048 HCPCS outpatient 138 103.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 122.82 89 999999999 107.64 131.1 percent of total billed charges "BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520)" 3018004801_1 CDM 301 RC 80048 HCPCS outpatient 138 103.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 122.82 89 999999999 107.64 131.1 percent of total billed charges "BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520)" 3018004801_1 CDM 301 RC 80048 HCPCS outpatient 138 103.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 124.2 90 999999999 107.64 131.1 percent of total billed charges "BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520)" 3018004801_1 CDM 301 RC 80048 HCPCS outpatient 138 103.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 131.1 95 999999999 107.64 131.1 percent of total billed charges "BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520)" 3018004801_1 CDM 301 RC 80048 HCPCS outpatient 138 103.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 131.1 95 999999999 107.64 131.1 percent of total billed charges "BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520)" 3018004801_1 CDM 301 RC 80048 HCPCS outpatient 138 103.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 122.82 89 999999999 107.64 131.1 percent of total billed charges "BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520)" 3018004801_1 CDM 301 RC 80048 HCPCS outpatient 138 103.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 121.44 88 999999999 107.64 131.1 percent of total billed charges "BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520)" 3018004801_1 CDM 301 RC 80048 HCPCS outpatient 138 103.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 122.82 89 999999999 107.64 131.1 percent of total billed charges ELECTROLYTE PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) POTASSIUM (84132) SODIUM (84295) 3018005101_1 CDM 301 RC 80051 HCPCS outpatient 89 66.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 80.1 90 999999999 69.42 84.55 percent of total billed charges ELECTROLYTE PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) POTASSIUM (84132) SODIUM (84295) 3018005101_1 CDM 301 RC 80051 HCPCS outpatient 89 66.75 AETNA MCR ADV AETNA MCR ADV 69.42 78 999999999 69.42 84.55 percent of total billed charges ELECTROLYTE PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) POTASSIUM (84132) SODIUM (84295) 3018005101_1 CDM 301 RC 80051 HCPCS outpatient 89 66.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 77.94 87.57 999999999 69.42 84.55 percent of total billed charges ELECTROLYTE PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) POTASSIUM (84132) SODIUM (84295) 3018005101_1 CDM 301 RC 80051 HCPCS outpatient 89 66.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 75.71 85.07 999999999 69.42 84.55 percent of total billed charges ELECTROLYTE PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) POTASSIUM (84132) SODIUM (84295) 3018005101_1 CDM 301 RC 80051 HCPCS outpatient 89 66.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 75.71 85.07 999999999 69.42 84.55 percent of total billed charges ELECTROLYTE PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) POTASSIUM (84132) SODIUM (84295) 3018005101_1 CDM 301 RC 80051 HCPCS outpatient 89 66.75 MOLINA MCAID MOLINA MCAID 74.23 83.4 999999999 69.42 84.55 percent of total billed charges ELECTROLYTE PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) POTASSIUM (84132) SODIUM (84295) 3018005101_1 CDM 301 RC 80051 HCPCS outpatient 89 66.75 MOLINA MCR ADV MOLINA MCR ADV 79.21 89 999999999 69.42 84.55 percent of total billed charges ELECTROLYTE PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) POTASSIUM (84132) SODIUM (84295) 3018005101_1 CDM 301 RC 80051 HCPCS outpatient 89 66.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 79.21 89 999999999 69.42 84.55 percent of total billed charges ELECTROLYTE PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) POTASSIUM (84132) SODIUM (84295) 3018005101_1 CDM 301 RC 80051 HCPCS outpatient 89 66.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 79.21 89 999999999 69.42 84.55 percent of total billed charges ELECTROLYTE PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) POTASSIUM (84132) SODIUM (84295) 3018005101_1 CDM 301 RC 80051 HCPCS outpatient 89 66.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 80.1 90 999999999 69.42 84.55 percent of total billed charges ELECTROLYTE PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) POTASSIUM (84132) SODIUM (84295) 3018005101_1 CDM 301 RC 80051 HCPCS outpatient 89 66.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 84.55 95 999999999 69.42 84.55 percent of total billed charges ELECTROLYTE PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) POTASSIUM (84132) SODIUM (84295) 3018005101_1 CDM 301 RC 80051 HCPCS outpatient 89 66.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 84.55 95 999999999 69.42 84.55 percent of total billed charges ELECTROLYTE PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) POTASSIUM (84132) SODIUM (84295) 3018005101_1 CDM 301 RC 80051 HCPCS outpatient 89 66.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 79.21 89 999999999 69.42 84.55 percent of total billed charges ELECTROLYTE PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) POTASSIUM (84132) SODIUM (84295) 3018005101_1 CDM 301 RC 80051 HCPCS outpatient 89 66.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 78.32 88 999999999 69.42 84.55 percent of total billed charges ELECTROLYTE PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) POTASSIUM (84132) SODIUM (84295) 3018005101_1 CDM 301 RC 80051 HCPCS outpatient 89 66.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 79.21 89 999999999 69.42 84.55 percent of total billed charges "COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) BILIRUBIN, TOTAL (82247) CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) PHOSPHATASE, ALKALINE (84075) POTASSIUM (84132) PROTEIN, TOTAL (84155) SODIUM (84295) TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460) TRANSFERASE, ASPARTATE AMINO (AST) (SGOT) (84450) UREA NITROGEN (BUN) (84520)" 3018005301_1 CDM 301 RC 80053 HCPCS outpatient 161 120.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 144.9 90 999999999 125.58 152.95 percent of total billed charges "COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) BILIRUBIN, TOTAL (82247) CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) PHOSPHATASE, ALKALINE (84075) POTASSIUM (84132) PROTEIN, TOTAL (84155) SODIUM (84295) TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460) TRANSFERASE, ASPARTATE AMINO (AST) (SGOT) (84450) UREA NITROGEN (BUN) (84520)" 3018005301_1 CDM 301 RC 80053 HCPCS outpatient 161 120.75 AETNA MCR ADV AETNA MCR ADV 125.58 78 999999999 125.58 152.95 percent of total billed charges "COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) BILIRUBIN, TOTAL (82247) CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) PHOSPHATASE, ALKALINE (84075) POTASSIUM (84132) PROTEIN, TOTAL (84155) SODIUM (84295) TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460) TRANSFERASE, ASPARTATE AMINO (AST) (SGOT) (84450) UREA NITROGEN (BUN) (84520)" 3018005301_1 CDM 301 RC 80053 HCPCS outpatient 161 120.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 140.99 87.57 999999999 125.58 152.95 percent of total billed charges "COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) BILIRUBIN, TOTAL (82247) CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) PHOSPHATASE, ALKALINE (84075) POTASSIUM (84132) PROTEIN, TOTAL (84155) SODIUM (84295) TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460) TRANSFERASE, ASPARTATE AMINO (AST) (SGOT) (84450) UREA NITROGEN (BUN) (84520)" 3018005301_1 CDM 301 RC 80053 HCPCS outpatient 161 120.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 136.96 85.07 999999999 125.58 152.95 percent of total billed charges "COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) BILIRUBIN, TOTAL (82247) CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) PHOSPHATASE, ALKALINE (84075) POTASSIUM (84132) PROTEIN, TOTAL (84155) SODIUM (84295) TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460) TRANSFERASE, ASPARTATE AMINO (AST) (SGOT) (84450) UREA NITROGEN (BUN) (84520)" 3018005301_1 CDM 301 RC 80053 HCPCS outpatient 161 120.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 136.96 85.07 999999999 125.58 152.95 percent of total billed charges "COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) BILIRUBIN, TOTAL (82247) CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) PHOSPHATASE, ALKALINE (84075) POTASSIUM (84132) PROTEIN, TOTAL (84155) SODIUM (84295) TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460) TRANSFERASE, ASPARTATE AMINO (AST) (SGOT) (84450) UREA NITROGEN (BUN) (84520)" 3018005301_1 CDM 301 RC 80053 HCPCS outpatient 161 120.75 MOLINA MCAID MOLINA MCAID 134.27 83.4 999999999 125.58 152.95 percent of total billed charges "COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) BILIRUBIN, TOTAL (82247) CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) PHOSPHATASE, ALKALINE (84075) POTASSIUM (84132) PROTEIN, TOTAL (84155) SODIUM (84295) TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460) TRANSFERASE, ASPARTATE AMINO (AST) (SGOT) (84450) UREA NITROGEN (BUN) (84520)" 3018005301_1 CDM 301 RC 80053 HCPCS outpatient 161 120.75 MOLINA MCR ADV MOLINA MCR ADV 143.29 89 999999999 125.58 152.95 percent of total billed charges "COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) BILIRUBIN, TOTAL (82247) CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) PHOSPHATASE, ALKALINE (84075) POTASSIUM (84132) PROTEIN, TOTAL (84155) SODIUM (84295) TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460) TRANSFERASE, ASPARTATE AMINO (AST) (SGOT) (84450) UREA NITROGEN (BUN) (84520)" 3018005301_1 CDM 301 RC 80053 HCPCS outpatient 161 120.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 143.29 89 999999999 125.58 152.95 percent of total billed charges "COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) BILIRUBIN, TOTAL (82247) CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) PHOSPHATASE, ALKALINE (84075) POTASSIUM (84132) PROTEIN, TOTAL (84155) SODIUM (84295) TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460) TRANSFERASE, ASPARTATE AMINO (AST) (SGOT) (84450) UREA NITROGEN (BUN) (84520)" 3018005301_1 CDM 301 RC 80053 HCPCS outpatient 161 120.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 143.29 89 999999999 125.58 152.95 percent of total billed charges "COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) BILIRUBIN, TOTAL (82247) CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) PHOSPHATASE, ALKALINE (84075) POTASSIUM (84132) PROTEIN, TOTAL (84155) SODIUM (84295) TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460) TRANSFERASE, ASPARTATE AMINO (AST) (SGOT) (84450) UREA NITROGEN (BUN) (84520)" 3018005301_1 CDM 301 RC 80053 HCPCS outpatient 161 120.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 144.9 90 999999999 125.58 152.95 percent of total billed charges "COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) BILIRUBIN, TOTAL (82247) CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) PHOSPHATASE, ALKALINE (84075) POTASSIUM (84132) PROTEIN, TOTAL (84155) SODIUM (84295) TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460) TRANSFERASE, ASPARTATE AMINO (AST) (SGOT) (84450) UREA NITROGEN (BUN) (84520)" 3018005301_1 CDM 301 RC 80053 HCPCS outpatient 161 120.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 152.95 95 999999999 125.58 152.95 percent of total billed charges "COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) BILIRUBIN, TOTAL (82247) CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) PHOSPHATASE, ALKALINE (84075) POTASSIUM (84132) PROTEIN, TOTAL (84155) SODIUM (84295) TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460) TRANSFERASE, ASPARTATE AMINO (AST) (SGOT) (84450) UREA NITROGEN (BUN) (84520)" 3018005301_1 CDM 301 RC 80053 HCPCS outpatient 161 120.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 152.95 95 999999999 125.58 152.95 percent of total billed charges "COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) BILIRUBIN, TOTAL (82247) CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) PHOSPHATASE, ALKALINE (84075) POTASSIUM (84132) PROTEIN, TOTAL (84155) SODIUM (84295) TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460) TRANSFERASE, ASPARTATE AMINO (AST) (SGOT) (84450) UREA NITROGEN (BUN) (84520)" 3018005301_1 CDM 301 RC 80053 HCPCS outpatient 161 120.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 143.29 89 999999999 125.58 152.95 percent of total billed charges "COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) BILIRUBIN, TOTAL (82247) CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) PHOSPHATASE, ALKALINE (84075) POTASSIUM (84132) PROTEIN, TOTAL (84155) SODIUM (84295) TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460) TRANSFERASE, ASPARTATE AMINO (AST) (SGOT) (84450) UREA NITROGEN (BUN) (84520)" 3018005301_1 CDM 301 RC 80053 HCPCS outpatient 161 120.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 141.68 88 999999999 125.58 152.95 percent of total billed charges "COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) BILIRUBIN, TOTAL (82247) CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) PHOSPHATASE, ALKALINE (84075) POTASSIUM (84132) PROTEIN, TOTAL (84155) SODIUM (84295) TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460) TRANSFERASE, ASPARTATE AMINO (AST) (SGOT) (84450) UREA NITROGEN (BUN) (84520)" 3018005301_1 CDM 301 RC 80053 HCPCS outpatient 161 120.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 143.29 89 999999999 125.58 152.95 percent of total billed charges "LIPID PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: CHOLESTEROL, SERUM, TOTAL (82465) LIPOPROTEIN, DIRECT MEASUREMENT, HIGH DENSITY CHOLESTEROL (HDL CHOLESTEROL) (83718) TRIGLYCERIDES (84478)" 3018006101_1 CDM 301 RC 80061 HCPCS outpatient 145 108.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 130.5 90 999999999 113.1 137.75 percent of total billed charges "LIPID PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: CHOLESTEROL, SERUM, TOTAL (82465) LIPOPROTEIN, DIRECT MEASUREMENT, HIGH DENSITY CHOLESTEROL (HDL CHOLESTEROL) (83718) TRIGLYCERIDES (84478)" 3018006101_1 CDM 301 RC 80061 HCPCS outpatient 145 108.75 AETNA MCR ADV AETNA MCR ADV 113.1 78 999999999 113.1 137.75 percent of total billed charges "LIPID PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: CHOLESTEROL, SERUM, TOTAL (82465) LIPOPROTEIN, DIRECT MEASUREMENT, HIGH DENSITY CHOLESTEROL (HDL CHOLESTEROL) (83718) TRIGLYCERIDES (84478)" 3018006101_1 CDM 301 RC 80061 HCPCS outpatient 145 108.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 126.98 87.57 999999999 113.1 137.75 percent of total billed charges "LIPID PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: CHOLESTEROL, SERUM, TOTAL (82465) LIPOPROTEIN, DIRECT MEASUREMENT, HIGH DENSITY CHOLESTEROL (HDL CHOLESTEROL) (83718) TRIGLYCERIDES (84478)" 3018006101_1 CDM 301 RC 80061 HCPCS outpatient 145 108.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 123.35 85.07 999999999 113.1 137.75 percent of total billed charges "LIPID PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: CHOLESTEROL, SERUM, TOTAL (82465) LIPOPROTEIN, DIRECT MEASUREMENT, HIGH DENSITY CHOLESTEROL (HDL CHOLESTEROL) (83718) TRIGLYCERIDES (84478)" 3018006101_1 CDM 301 RC 80061 HCPCS outpatient 145 108.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 123.35 85.07 999999999 113.1 137.75 percent of total billed charges "LIPID PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: CHOLESTEROL, SERUM, TOTAL (82465) LIPOPROTEIN, DIRECT MEASUREMENT, HIGH DENSITY CHOLESTEROL (HDL CHOLESTEROL) (83718) TRIGLYCERIDES (84478)" 3018006101_1 CDM 301 RC 80061 HCPCS outpatient 145 108.75 MOLINA MCAID MOLINA MCAID 120.93 83.4 999999999 113.1 137.75 percent of total billed charges "LIPID PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: CHOLESTEROL, SERUM, TOTAL (82465) LIPOPROTEIN, DIRECT MEASUREMENT, HIGH DENSITY CHOLESTEROL (HDL CHOLESTEROL) (83718) TRIGLYCERIDES (84478)" 3018006101_1 CDM 301 RC 80061 HCPCS outpatient 145 108.75 MOLINA MCR ADV MOLINA MCR ADV 129.05 89 999999999 113.1 137.75 percent of total billed charges "LIPID PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: CHOLESTEROL, SERUM, TOTAL (82465) LIPOPROTEIN, DIRECT MEASUREMENT, HIGH DENSITY CHOLESTEROL (HDL CHOLESTEROL) (83718) TRIGLYCERIDES (84478)" 3018006101_1 CDM 301 RC 80061 HCPCS outpatient 145 108.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 129.05 89 999999999 113.1 137.75 percent of total billed charges "LIPID PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: CHOLESTEROL, SERUM, TOTAL (82465) LIPOPROTEIN, DIRECT MEASUREMENT, HIGH DENSITY CHOLESTEROL (HDL CHOLESTEROL) (83718) TRIGLYCERIDES (84478)" 3018006101_1 CDM 301 RC 80061 HCPCS outpatient 145 108.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 129.05 89 999999999 113.1 137.75 percent of total billed charges "LIPID PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: CHOLESTEROL, SERUM, TOTAL (82465) LIPOPROTEIN, DIRECT MEASUREMENT, HIGH DENSITY CHOLESTEROL (HDL CHOLESTEROL) (83718) TRIGLYCERIDES (84478)" 3018006101_1 CDM 301 RC 80061 HCPCS outpatient 145 108.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 130.5 90 999999999 113.1 137.75 percent of total billed charges "LIPID PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: CHOLESTEROL, SERUM, TOTAL (82465) LIPOPROTEIN, DIRECT MEASUREMENT, HIGH DENSITY CHOLESTEROL (HDL CHOLESTEROL) (83718) TRIGLYCERIDES (84478)" 3018006101_1 CDM 301 RC 80061 HCPCS outpatient 145 108.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 137.75 95 999999999 113.1 137.75 percent of total billed charges "LIPID PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: CHOLESTEROL, SERUM, TOTAL (82465) LIPOPROTEIN, DIRECT MEASUREMENT, HIGH DENSITY CHOLESTEROL (HDL CHOLESTEROL) (83718) TRIGLYCERIDES (84478)" 3018006101_1 CDM 301 RC 80061 HCPCS outpatient 145 108.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 137.75 95 999999999 113.1 137.75 percent of total billed charges "LIPID PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: CHOLESTEROL, SERUM, TOTAL (82465) LIPOPROTEIN, DIRECT MEASUREMENT, HIGH DENSITY CHOLESTEROL (HDL CHOLESTEROL) (83718) TRIGLYCERIDES (84478)" 3018006101_1 CDM 301 RC 80061 HCPCS outpatient 145 108.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 129.05 89 999999999 113.1 137.75 percent of total billed charges "LIPID PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: CHOLESTEROL, SERUM, TOTAL (82465) LIPOPROTEIN, DIRECT MEASUREMENT, HIGH DENSITY CHOLESTEROL (HDL CHOLESTEROL) (83718) TRIGLYCERIDES (84478)" 3018006101_1 CDM 301 RC 80061 HCPCS outpatient 145 108.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 127.6 88 999999999 113.1 137.75 percent of total billed charges "LIPID PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: CHOLESTEROL, SERUM, TOTAL (82465) LIPOPROTEIN, DIRECT MEASUREMENT, HIGH DENSITY CHOLESTEROL (HDL CHOLESTEROL) (83718) TRIGLYCERIDES (84478)" 3018006101_1 CDM 301 RC 80061 HCPCS outpatient 145 108.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 129.05 89 999999999 113.1 137.75 percent of total billed charges "RENAL FUNCTION PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) PHOSPHORUS INORGANIC (PHOSPHATE) (84100) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520)" 3018006901_1 CDM 301 RC 80069 HCPCS outpatient 119 89.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 107.1 90 999999999 92.82 113.05 percent of total billed charges "RENAL FUNCTION PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) PHOSPHORUS INORGANIC (PHOSPHATE) (84100) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520)" 3018006901_1 CDM 301 RC 80069 HCPCS outpatient 119 89.25 AETNA MCR ADV AETNA MCR ADV 92.82 78 999999999 92.82 113.05 percent of total billed charges "RENAL FUNCTION PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) PHOSPHORUS INORGANIC (PHOSPHATE) (84100) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520)" 3018006901_1 CDM 301 RC 80069 HCPCS outpatient 119 89.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 104.21 87.57 999999999 92.82 113.05 percent of total billed charges "RENAL FUNCTION PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) PHOSPHORUS INORGANIC (PHOSPHATE) (84100) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520)" 3018006901_1 CDM 301 RC 80069 HCPCS outpatient 119 89.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 101.23 85.07 999999999 92.82 113.05 percent of total billed charges "RENAL FUNCTION PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) PHOSPHORUS INORGANIC (PHOSPHATE) (84100) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520)" 3018006901_1 CDM 301 RC 80069 HCPCS outpatient 119 89.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 101.23 85.07 999999999 92.82 113.05 percent of total billed charges "RENAL FUNCTION PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) PHOSPHORUS INORGANIC (PHOSPHATE) (84100) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520)" 3018006901_1 CDM 301 RC 80069 HCPCS outpatient 119 89.25 MOLINA MCAID MOLINA MCAID 99.25 83.4 999999999 92.82 113.05 percent of total billed charges "RENAL FUNCTION PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) PHOSPHORUS INORGANIC (PHOSPHATE) (84100) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520)" 3018006901_1 CDM 301 RC 80069 HCPCS outpatient 119 89.25 MOLINA MCR ADV MOLINA MCR ADV 105.91 89 999999999 92.82 113.05 percent of total billed charges "RENAL FUNCTION PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) PHOSPHORUS INORGANIC (PHOSPHATE) (84100) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520)" 3018006901_1 CDM 301 RC 80069 HCPCS outpatient 119 89.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 105.91 89 999999999 92.82 113.05 percent of total billed charges "RENAL FUNCTION PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) PHOSPHORUS INORGANIC (PHOSPHATE) (84100) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520)" 3018006901_1 CDM 301 RC 80069 HCPCS outpatient 119 89.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 105.91 89 999999999 92.82 113.05 percent of total billed charges "RENAL FUNCTION PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) PHOSPHORUS INORGANIC (PHOSPHATE) (84100) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520)" 3018006901_1 CDM 301 RC 80069 HCPCS outpatient 119 89.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 107.1 90 999999999 92.82 113.05 percent of total billed charges "RENAL FUNCTION PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) PHOSPHORUS INORGANIC (PHOSPHATE) (84100) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520)" 3018006901_1 CDM 301 RC 80069 HCPCS outpatient 119 89.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 113.05 95 999999999 92.82 113.05 percent of total billed charges "RENAL FUNCTION PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) PHOSPHORUS INORGANIC (PHOSPHATE) (84100) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520)" 3018006901_1 CDM 301 RC 80069 HCPCS outpatient 119 89.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 113.05 95 999999999 92.82 113.05 percent of total billed charges "RENAL FUNCTION PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) PHOSPHORUS INORGANIC (PHOSPHATE) (84100) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520)" 3018006901_1 CDM 301 RC 80069 HCPCS outpatient 119 89.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 105.91 89 999999999 92.82 113.05 percent of total billed charges "RENAL FUNCTION PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) PHOSPHORUS INORGANIC (PHOSPHATE) (84100) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520)" 3018006901_1 CDM 301 RC 80069 HCPCS outpatient 119 89.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 104.72 88 999999999 92.82 113.05 percent of total billed charges "RENAL FUNCTION PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) PHOSPHORUS INORGANIC (PHOSPHATE) (84100) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520)" 3018006901_1 CDM 301 RC 80069 HCPCS outpatient 119 89.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 105.91 89 999999999 92.82 113.05 percent of total billed charges "ACUTE HEPATITIS PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: HEPATITIS A ANTIBODY (HAAB), IGM ANTIBODY (86709) HEPATITIS B CORE ANTIBODY (HBCAB), IGM ANTIBODY (86705) HEPATITIS B SURFACE ANTIGEN (HBSAG) (87340) HEPATITIS C ANTIBODY (86803)" 3018007401_1 CDM 301 RC 80074 HCPCS outpatient 332 249 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 298.8 90 999999999 258.96 315.4 percent of total billed charges "ACUTE HEPATITIS PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: HEPATITIS A ANTIBODY (HAAB), IGM ANTIBODY (86709) HEPATITIS B CORE ANTIBODY (HBCAB), IGM ANTIBODY (86705) HEPATITIS B SURFACE ANTIGEN (HBSAG) (87340) HEPATITIS C ANTIBODY (86803)" 3018007401_1 CDM 301 RC 80074 HCPCS outpatient 332 249 AETNA MCR ADV AETNA MCR ADV 258.96 78 999999999 258.96 315.4 percent of total billed charges "ACUTE HEPATITIS PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: HEPATITIS A ANTIBODY (HAAB), IGM ANTIBODY (86709) HEPATITIS B CORE ANTIBODY (HBCAB), IGM ANTIBODY (86705) HEPATITIS B SURFACE ANTIGEN (HBSAG) (87340) HEPATITIS C ANTIBODY (86803)" 3018007401_1 CDM 301 RC 80074 HCPCS outpatient 332 249 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 290.73 87.57 999999999 258.96 315.4 percent of total billed charges "ACUTE HEPATITIS PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: HEPATITIS A ANTIBODY (HAAB), IGM ANTIBODY (86709) HEPATITIS B CORE ANTIBODY (HBCAB), IGM ANTIBODY (86705) HEPATITIS B SURFACE ANTIGEN (HBSAG) (87340) HEPATITIS C ANTIBODY (86803)" 3018007401_1 CDM 301 RC 80074 HCPCS outpatient 332 249 COORDINATED CARE MCAID COORDINATED CARE MCAID 282.43 85.07 999999999 258.96 315.4 percent of total billed charges "ACUTE HEPATITIS PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: HEPATITIS A ANTIBODY (HAAB), IGM ANTIBODY (86709) HEPATITIS B CORE ANTIBODY (HBCAB), IGM ANTIBODY (86705) HEPATITIS B SURFACE ANTIGEN (HBSAG) (87340) HEPATITIS C ANTIBODY (86803)" 3018007401_1 CDM 301 RC 80074 HCPCS outpatient 332 249 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 282.43 85.07 999999999 258.96 315.4 percent of total billed charges "ACUTE HEPATITIS PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: HEPATITIS A ANTIBODY (HAAB), IGM ANTIBODY (86709) HEPATITIS B CORE ANTIBODY (HBCAB), IGM ANTIBODY (86705) HEPATITIS B SURFACE ANTIGEN (HBSAG) (87340) HEPATITIS C ANTIBODY (86803)" 3018007401_1 CDM 301 RC 80074 HCPCS outpatient 332 249 MOLINA MCAID MOLINA MCAID 276.89 83.4 999999999 258.96 315.4 percent of total billed charges "ACUTE HEPATITIS PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: HEPATITIS A ANTIBODY (HAAB), IGM ANTIBODY (86709) HEPATITIS B CORE ANTIBODY (HBCAB), IGM ANTIBODY (86705) HEPATITIS B SURFACE ANTIGEN (HBSAG) (87340) HEPATITIS C ANTIBODY (86803)" 3018007401_1 CDM 301 RC 80074 HCPCS outpatient 332 249 MOLINA MCR ADV MOLINA MCR ADV 295.48 89 999999999 258.96 315.4 percent of total billed charges "ACUTE HEPATITIS PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: HEPATITIS A ANTIBODY (HAAB), IGM ANTIBODY (86709) HEPATITIS B CORE ANTIBODY (HBCAB), IGM ANTIBODY (86705) HEPATITIS B SURFACE ANTIGEN (HBSAG) (87340) HEPATITIS C ANTIBODY (86803)" 3018007401_1 CDM 301 RC 80074 HCPCS outpatient 332 249 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 295.48 89 999999999 258.96 315.4 percent of total billed charges "ACUTE HEPATITIS PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: HEPATITIS A ANTIBODY (HAAB), IGM ANTIBODY (86709) HEPATITIS B CORE ANTIBODY (HBCAB), IGM ANTIBODY (86705) HEPATITIS B SURFACE ANTIGEN (HBSAG) (87340) HEPATITIS C ANTIBODY (86803)" 3018007401_1 CDM 301 RC 80074 HCPCS outpatient 332 249 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 295.48 89 999999999 258.96 315.4 percent of total billed charges "ACUTE HEPATITIS PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: HEPATITIS A ANTIBODY (HAAB), IGM ANTIBODY (86709) HEPATITIS B CORE ANTIBODY (HBCAB), IGM ANTIBODY (86705) HEPATITIS B SURFACE ANTIGEN (HBSAG) (87340) HEPATITIS C ANTIBODY (86803)" 3018007401_1 CDM 301 RC 80074 HCPCS outpatient 332 249 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 298.8 90 999999999 258.96 315.4 percent of total billed charges "ACUTE HEPATITIS PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: HEPATITIS A ANTIBODY (HAAB), IGM ANTIBODY (86709) HEPATITIS B CORE ANTIBODY (HBCAB), IGM ANTIBODY (86705) HEPATITIS B SURFACE ANTIGEN (HBSAG) (87340) HEPATITIS C ANTIBODY (86803)" 3018007401_1 CDM 301 RC 80074 HCPCS outpatient 332 249 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 315.4 95 999999999 258.96 315.4 percent of total billed charges "ACUTE HEPATITIS PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: HEPATITIS A ANTIBODY (HAAB), IGM ANTIBODY (86709) HEPATITIS B CORE ANTIBODY (HBCAB), IGM ANTIBODY (86705) HEPATITIS B SURFACE ANTIGEN (HBSAG) (87340) HEPATITIS C ANTIBODY (86803)" 3018007401_1 CDM 301 RC 80074 HCPCS outpatient 332 249 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 315.4 95 999999999 258.96 315.4 percent of total billed charges "ACUTE HEPATITIS PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: HEPATITIS A ANTIBODY (HAAB), IGM ANTIBODY (86709) HEPATITIS B CORE ANTIBODY (HBCAB), IGM ANTIBODY (86705) HEPATITIS B SURFACE ANTIGEN (HBSAG) (87340) HEPATITIS C ANTIBODY (86803)" 3018007401_1 CDM 301 RC 80074 HCPCS outpatient 332 249 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 295.48 89 999999999 258.96 315.4 percent of total billed charges "ACUTE HEPATITIS PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: HEPATITIS A ANTIBODY (HAAB), IGM ANTIBODY (86709) HEPATITIS B CORE ANTIBODY (HBCAB), IGM ANTIBODY (86705) HEPATITIS B SURFACE ANTIGEN (HBSAG) (87340) HEPATITIS C ANTIBODY (86803)" 3018007401_1 CDM 301 RC 80074 HCPCS outpatient 332 249 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 292.16 88 999999999 258.96 315.4 percent of total billed charges "ACUTE HEPATITIS PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: HEPATITIS A ANTIBODY (HAAB), IGM ANTIBODY (86709) HEPATITIS B CORE ANTIBODY (HBCAB), IGM ANTIBODY (86705) HEPATITIS B SURFACE ANTIGEN (HBSAG) (87340) HEPATITIS C ANTIBODY (86803)" 3018007401_1 CDM 301 RC 80074 HCPCS outpatient 332 249 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 295.48 89 999999999 258.96 315.4 percent of total billed charges "HEPATIC FUNCTION PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) BILIRUBIN, TOTAL (82247) BILIRUBIN, DIRECT (82248) PHOSPHATASE, ALKALINE (84075) PROTEIN, TOTAL (84155) TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460) TRANSFERASE, ASPARTATE AMINO (AST) (SGOT) (84450)" 3018007601_1 CDM 301 RC 80076 HCPCS outpatient 114 85.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 102.6 90 999999999 88.92 108.3 percent of total billed charges "HEPATIC FUNCTION PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) BILIRUBIN, TOTAL (82247) BILIRUBIN, DIRECT (82248) PHOSPHATASE, ALKALINE (84075) PROTEIN, TOTAL (84155) TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460) TRANSFERASE, ASPARTATE AMINO (AST) (SGOT) (84450)" 3018007601_1 CDM 301 RC 80076 HCPCS outpatient 114 85.5 AETNA MCR ADV AETNA MCR ADV 88.92 78 999999999 88.92 108.3 percent of total billed charges "HEPATIC FUNCTION PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) BILIRUBIN, TOTAL (82247) BILIRUBIN, DIRECT (82248) PHOSPHATASE, ALKALINE (84075) PROTEIN, TOTAL (84155) TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460) TRANSFERASE, ASPARTATE AMINO (AST) (SGOT) (84450)" 3018007601_1 CDM 301 RC 80076 HCPCS outpatient 114 85.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 99.83 87.57 999999999 88.92 108.3 percent of total billed charges "HEPATIC FUNCTION PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) BILIRUBIN, TOTAL (82247) BILIRUBIN, DIRECT (82248) PHOSPHATASE, ALKALINE (84075) PROTEIN, TOTAL (84155) TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460) TRANSFERASE, ASPARTATE AMINO (AST) (SGOT) (84450)" 3018007601_1 CDM 301 RC 80076 HCPCS outpatient 114 85.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 96.98 85.07 999999999 88.92 108.3 percent of total billed charges "HEPATIC FUNCTION PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) BILIRUBIN, TOTAL (82247) BILIRUBIN, DIRECT (82248) PHOSPHATASE, ALKALINE (84075) PROTEIN, TOTAL (84155) TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460) TRANSFERASE, ASPARTATE AMINO (AST) (SGOT) (84450)" 3018007601_1 CDM 301 RC 80076 HCPCS outpatient 114 85.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 96.98 85.07 999999999 88.92 108.3 percent of total billed charges "HEPATIC FUNCTION PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) BILIRUBIN, TOTAL (82247) BILIRUBIN, DIRECT (82248) PHOSPHATASE, ALKALINE (84075) PROTEIN, TOTAL (84155) TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460) TRANSFERASE, ASPARTATE AMINO (AST) (SGOT) (84450)" 3018007601_1 CDM 301 RC 80076 HCPCS outpatient 114 85.5 MOLINA MCAID MOLINA MCAID 95.08 83.4 999999999 88.92 108.3 percent of total billed charges "HEPATIC FUNCTION PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) BILIRUBIN, TOTAL (82247) BILIRUBIN, DIRECT (82248) PHOSPHATASE, ALKALINE (84075) PROTEIN, TOTAL (84155) TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460) TRANSFERASE, ASPARTATE AMINO (AST) (SGOT) (84450)" 3018007601_1 CDM 301 RC 80076 HCPCS outpatient 114 85.5 MOLINA MCR ADV MOLINA MCR ADV 101.46 89 999999999 88.92 108.3 percent of total billed charges "HEPATIC FUNCTION PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) BILIRUBIN, TOTAL (82247) BILIRUBIN, DIRECT (82248) PHOSPHATASE, ALKALINE (84075) PROTEIN, TOTAL (84155) TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460) TRANSFERASE, ASPARTATE AMINO (AST) (SGOT) (84450)" 3018007601_1 CDM 301 RC 80076 HCPCS outpatient 114 85.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 101.46 89 999999999 88.92 108.3 percent of total billed charges "HEPATIC FUNCTION PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) BILIRUBIN, TOTAL (82247) BILIRUBIN, DIRECT (82248) PHOSPHATASE, ALKALINE (84075) PROTEIN, TOTAL (84155) TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460) TRANSFERASE, ASPARTATE AMINO (AST) (SGOT) (84450)" 3018007601_1 CDM 301 RC 80076 HCPCS outpatient 114 85.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 101.46 89 999999999 88.92 108.3 percent of total billed charges "HEPATIC FUNCTION PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) BILIRUBIN, TOTAL (82247) BILIRUBIN, DIRECT (82248) PHOSPHATASE, ALKALINE (84075) PROTEIN, TOTAL (84155) TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460) TRANSFERASE, ASPARTATE AMINO (AST) (SGOT) (84450)" 3018007601_1 CDM 301 RC 80076 HCPCS outpatient 114 85.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 102.6 90 999999999 88.92 108.3 percent of total billed charges "HEPATIC FUNCTION PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) BILIRUBIN, TOTAL (82247) BILIRUBIN, DIRECT (82248) PHOSPHATASE, ALKALINE (84075) PROTEIN, TOTAL (84155) TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460) TRANSFERASE, ASPARTATE AMINO (AST) (SGOT) (84450)" 3018007601_1 CDM 301 RC 80076 HCPCS outpatient 114 85.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 108.3 95 999999999 88.92 108.3 percent of total billed charges "HEPATIC FUNCTION PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) BILIRUBIN, TOTAL (82247) BILIRUBIN, DIRECT (82248) PHOSPHATASE, ALKALINE (84075) PROTEIN, TOTAL (84155) TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460) TRANSFERASE, ASPARTATE AMINO (AST) (SGOT) (84450)" 3018007601_1 CDM 301 RC 80076 HCPCS outpatient 114 85.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 108.3 95 999999999 88.92 108.3 percent of total billed charges "HEPATIC FUNCTION PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) BILIRUBIN, TOTAL (82247) BILIRUBIN, DIRECT (82248) PHOSPHATASE, ALKALINE (84075) PROTEIN, TOTAL (84155) TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460) TRANSFERASE, ASPARTATE AMINO (AST) (SGOT) (84450)" 3018007601_1 CDM 301 RC 80076 HCPCS outpatient 114 85.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 101.46 89 999999999 88.92 108.3 percent of total billed charges "HEPATIC FUNCTION PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) BILIRUBIN, TOTAL (82247) BILIRUBIN, DIRECT (82248) PHOSPHATASE, ALKALINE (84075) PROTEIN, TOTAL (84155) TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460) TRANSFERASE, ASPARTATE AMINO (AST) (SGOT) (84450)" 3018007601_1 CDM 301 RC 80076 HCPCS outpatient 114 85.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 100.32 88 999999999 88.92 108.3 percent of total billed charges "HEPATIC FUNCTION PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) BILIRUBIN, TOTAL (82247) BILIRUBIN, DIRECT (82248) PHOSPHATASE, ALKALINE (84075) PROTEIN, TOTAL (84155) TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460) TRANSFERASE, ASPARTATE AMINO (AST) (SGOT) (84450)" 3018007601_1 CDM 301 RC 80076 HCPCS outpatient 114 85.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 101.46 89 999999999 88.92 108.3 percent of total billed charges CARBAMAZEPINE; TOTAL 3018015601_1 CDM 301 RC 80156 HCPCS outpatient 120 90 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 108 90 999999999 93.6 114 percent of total billed charges CARBAMAZEPINE; TOTAL 3018015601_1 CDM 301 RC 80156 HCPCS outpatient 120 90 AETNA MCR ADV AETNA MCR ADV 93.6 78 999999999 93.6 114 percent of total billed charges CARBAMAZEPINE; TOTAL 3018015601_1 CDM 301 RC 80156 HCPCS outpatient 120 90 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 105.08 87.57 999999999 93.6 114 percent of total billed charges CARBAMAZEPINE; TOTAL 3018015601_1 CDM 301 RC 80156 HCPCS outpatient 120 90 COORDINATED CARE MCAID COORDINATED CARE MCAID 102.08 85.07 999999999 93.6 114 percent of total billed charges CARBAMAZEPINE; TOTAL 3018015601_1 CDM 301 RC 80156 HCPCS outpatient 120 90 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 102.08 85.07 999999999 93.6 114 percent of total billed charges CARBAMAZEPINE; TOTAL 3018015601_1 CDM 301 RC 80156 HCPCS outpatient 120 90 MOLINA MCAID MOLINA MCAID 100.08 83.4 999999999 93.6 114 percent of total billed charges CARBAMAZEPINE; TOTAL 3018015601_1 CDM 301 RC 80156 HCPCS outpatient 120 90 MOLINA MCR ADV MOLINA MCR ADV 106.8 89 999999999 93.6 114 percent of total billed charges CARBAMAZEPINE; TOTAL 3018015601_1 CDM 301 RC 80156 HCPCS outpatient 120 90 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 106.8 89 999999999 93.6 114 percent of total billed charges CARBAMAZEPINE; TOTAL 3018015601_1 CDM 301 RC 80156 HCPCS outpatient 120 90 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 106.8 89 999999999 93.6 114 percent of total billed charges CARBAMAZEPINE; TOTAL 3018015601_1 CDM 301 RC 80156 HCPCS outpatient 120 90 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 108 90 999999999 93.6 114 percent of total billed charges CARBAMAZEPINE; TOTAL 3018015601_1 CDM 301 RC 80156 HCPCS outpatient 120 90 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 114 95 999999999 93.6 114 percent of total billed charges CARBAMAZEPINE; TOTAL 3018015601_1 CDM 301 RC 80156 HCPCS outpatient 120 90 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 114 95 999999999 93.6 114 percent of total billed charges CARBAMAZEPINE; TOTAL 3018015601_1 CDM 301 RC 80156 HCPCS outpatient 120 90 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 106.8 89 999999999 93.6 114 percent of total billed charges CARBAMAZEPINE; TOTAL 3018015601_1 CDM 301 RC 80156 HCPCS outpatient 120 90 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 105.6 88 999999999 93.6 114 percent of total billed charges CARBAMAZEPINE; TOTAL 3018015601_1 CDM 301 RC 80156 HCPCS outpatient 120 90 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 106.8 89 999999999 93.6 114 percent of total billed charges CYCLOSPORINE 3018015801_1 CDM 301 RC 80158 HCPCS outpatient 103 77.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 92.7 90 999999999 80.34 97.85 percent of total billed charges CYCLOSPORINE 3018015801_1 CDM 301 RC 80158 HCPCS outpatient 103 77.25 AETNA MCR ADV AETNA MCR ADV 80.34 78 999999999 80.34 97.85 percent of total billed charges CYCLOSPORINE 3018015801_1 CDM 301 RC 80158 HCPCS outpatient 103 77.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 90.2 87.57 999999999 80.34 97.85 percent of total billed charges CYCLOSPORINE 3018015801_1 CDM 301 RC 80158 HCPCS outpatient 103 77.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 87.62 85.07 999999999 80.34 97.85 percent of total billed charges CYCLOSPORINE 3018015801_1 CDM 301 RC 80158 HCPCS outpatient 103 77.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 87.62 85.07 999999999 80.34 97.85 percent of total billed charges CYCLOSPORINE 3018015801_1 CDM 301 RC 80158 HCPCS outpatient 103 77.25 MOLINA MCAID MOLINA MCAID 85.9 83.4 999999999 80.34 97.85 percent of total billed charges CYCLOSPORINE 3018015801_1 CDM 301 RC 80158 HCPCS outpatient 103 77.25 MOLINA MCR ADV MOLINA MCR ADV 91.67 89 999999999 80.34 97.85 percent of total billed charges CYCLOSPORINE 3018015801_1 CDM 301 RC 80158 HCPCS outpatient 103 77.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 91.67 89 999999999 80.34 97.85 percent of total billed charges CYCLOSPORINE 3018015801_1 CDM 301 RC 80158 HCPCS outpatient 103 77.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 91.67 89 999999999 80.34 97.85 percent of total billed charges CYCLOSPORINE 3018015801_1 CDM 301 RC 80158 HCPCS outpatient 103 77.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 92.7 90 999999999 80.34 97.85 percent of total billed charges CYCLOSPORINE 3018015801_1 CDM 301 RC 80158 HCPCS outpatient 103 77.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 97.85 95 999999999 80.34 97.85 percent of total billed charges CYCLOSPORINE 3018015801_1 CDM 301 RC 80158 HCPCS outpatient 103 77.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 97.85 95 999999999 80.34 97.85 percent of total billed charges CYCLOSPORINE 3018015801_1 CDM 301 RC 80158 HCPCS outpatient 103 77.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 91.67 89 999999999 80.34 97.85 percent of total billed charges CYCLOSPORINE 3018015801_1 CDM 301 RC 80158 HCPCS outpatient 103 77.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 90.64 88 999999999 80.34 97.85 percent of total billed charges CYCLOSPORINE 3018015801_1 CDM 301 RC 80158 HCPCS outpatient 103 77.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 91.67 89 999999999 80.34 97.85 percent of total billed charges DIGOXIN; TOTAL 3018016201_1 CDM 301 RC 80162 HCPCS outpatient 156 117 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 140.4 90 999999999 121.68 148.2 percent of total billed charges DIGOXIN; TOTAL 3018016201_1 CDM 301 RC 80162 HCPCS outpatient 156 117 AETNA MCR ADV AETNA MCR ADV 121.68 78 999999999 121.68 148.2 percent of total billed charges DIGOXIN; TOTAL 3018016201_1 CDM 301 RC 80162 HCPCS outpatient 156 117 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 136.61 87.57 999999999 121.68 148.2 percent of total billed charges DIGOXIN; TOTAL 3018016201_1 CDM 301 RC 80162 HCPCS outpatient 156 117 COORDINATED CARE MCAID COORDINATED CARE MCAID 132.71 85.07 999999999 121.68 148.2 percent of total billed charges DIGOXIN; TOTAL 3018016201_1 CDM 301 RC 80162 HCPCS outpatient 156 117 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 132.71 85.07 999999999 121.68 148.2 percent of total billed charges DIGOXIN; TOTAL 3018016201_1 CDM 301 RC 80162 HCPCS outpatient 156 117 MOLINA MCAID MOLINA MCAID 130.1 83.4 999999999 121.68 148.2 percent of total billed charges DIGOXIN; TOTAL 3018016201_1 CDM 301 RC 80162 HCPCS outpatient 156 117 MOLINA MCR ADV MOLINA MCR ADV 138.84 89 999999999 121.68 148.2 percent of total billed charges DIGOXIN; TOTAL 3018016201_1 CDM 301 RC 80162 HCPCS outpatient 156 117 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 138.84 89 999999999 121.68 148.2 percent of total billed charges DIGOXIN; TOTAL 3018016201_1 CDM 301 RC 80162 HCPCS outpatient 156 117 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 138.84 89 999999999 121.68 148.2 percent of total billed charges DIGOXIN; TOTAL 3018016201_1 CDM 301 RC 80162 HCPCS outpatient 156 117 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 140.4 90 999999999 121.68 148.2 percent of total billed charges DIGOXIN; TOTAL 3018016201_1 CDM 301 RC 80162 HCPCS outpatient 156 117 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 148.2 95 999999999 121.68 148.2 percent of total billed charges DIGOXIN; TOTAL 3018016201_1 CDM 301 RC 80162 HCPCS outpatient 156 117 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 148.2 95 999999999 121.68 148.2 percent of total billed charges DIGOXIN; TOTAL 3018016201_1 CDM 301 RC 80162 HCPCS outpatient 156 117 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 138.84 89 999999999 121.68 148.2 percent of total billed charges DIGOXIN; TOTAL 3018016201_1 CDM 301 RC 80162 HCPCS outpatient 156 117 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 137.28 88 999999999 121.68 148.2 percent of total billed charges DIGOXIN; TOTAL 3018016201_1 CDM 301 RC 80162 HCPCS outpatient 156 117 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 138.84 89 999999999 121.68 148.2 percent of total billed charges VALPROIC ACID (DIPROPYLACETIC ACID); TOTAL 3018016401_1 CDM 301 RC 80164 HCPCS outpatient 128 96 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 115.2 90 999999999 99.84 121.6 percent of total billed charges VALPROIC ACID (DIPROPYLACETIC ACID); TOTAL 3018016401_1 CDM 301 RC 80164 HCPCS outpatient 128 96 AETNA MCR ADV AETNA MCR ADV 99.84 78 999999999 99.84 121.6 percent of total billed charges VALPROIC ACID (DIPROPYLACETIC ACID); TOTAL 3018016401_1 CDM 301 RC 80164 HCPCS outpatient 128 96 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 112.09 87.57 999999999 99.84 121.6 percent of total billed charges VALPROIC ACID (DIPROPYLACETIC ACID); TOTAL 3018016401_1 CDM 301 RC 80164 HCPCS outpatient 128 96 COORDINATED CARE MCAID COORDINATED CARE MCAID 108.89 85.07 999999999 99.84 121.6 percent of total billed charges VALPROIC ACID (DIPROPYLACETIC ACID); TOTAL 3018016401_1 CDM 301 RC 80164 HCPCS outpatient 128 96 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 108.89 85.07 999999999 99.84 121.6 percent of total billed charges VALPROIC ACID (DIPROPYLACETIC ACID); TOTAL 3018016401_1 CDM 301 RC 80164 HCPCS outpatient 128 96 MOLINA MCAID MOLINA MCAID 106.75 83.4 999999999 99.84 121.6 percent of total billed charges VALPROIC ACID (DIPROPYLACETIC ACID); TOTAL 3018016401_1 CDM 301 RC 80164 HCPCS outpatient 128 96 MOLINA MCR ADV MOLINA MCR ADV 113.92 89 999999999 99.84 121.6 percent of total billed charges VALPROIC ACID (DIPROPYLACETIC ACID); TOTAL 3018016401_1 CDM 301 RC 80164 HCPCS outpatient 128 96 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 113.92 89 999999999 99.84 121.6 percent of total billed charges VALPROIC ACID (DIPROPYLACETIC ACID); TOTAL 3018016401_1 CDM 301 RC 80164 HCPCS outpatient 128 96 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 113.92 89 999999999 99.84 121.6 percent of total billed charges VALPROIC ACID (DIPROPYLACETIC ACID); TOTAL 3018016401_1 CDM 301 RC 80164 HCPCS outpatient 128 96 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 115.2 90 999999999 99.84 121.6 percent of total billed charges VALPROIC ACID (DIPROPYLACETIC ACID); TOTAL 3018016401_1 CDM 301 RC 80164 HCPCS outpatient 128 96 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 121.6 95 999999999 99.84 121.6 percent of total billed charges VALPROIC ACID (DIPROPYLACETIC ACID); TOTAL 3018016401_1 CDM 301 RC 80164 HCPCS outpatient 128 96 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 121.6 95 999999999 99.84 121.6 percent of total billed charges VALPROIC ACID (DIPROPYLACETIC ACID); TOTAL 3018016401_1 CDM 301 RC 80164 HCPCS outpatient 128 96 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 113.92 89 999999999 99.84 121.6 percent of total billed charges VALPROIC ACID (DIPROPYLACETIC ACID); TOTAL 3018016401_1 CDM 301 RC 80164 HCPCS outpatient 128 96 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 112.64 88 999999999 99.84 121.6 percent of total billed charges VALPROIC ACID (DIPROPYLACETIC ACID); TOTAL 3018016401_1 CDM 301 RC 80164 HCPCS outpatient 128 96 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 113.92 89 999999999 99.84 121.6 percent of total billed charges LEVETIRACETAM 3018017701_1 CDM 301 RC 80177 HCPCS outpatient 212 159 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 190.8 90 999999999 165.36 201.4 percent of total billed charges LEVETIRACETAM 3018017701_1 CDM 301 RC 80177 HCPCS outpatient 212 159 AETNA MCR ADV AETNA MCR ADV 165.36 78 999999999 165.36 201.4 percent of total billed charges LEVETIRACETAM 3018017701_1 CDM 301 RC 80177 HCPCS outpatient 212 159 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 185.65 87.57 999999999 165.36 201.4 percent of total billed charges LEVETIRACETAM 3018017701_1 CDM 301 RC 80177 HCPCS outpatient 212 159 COORDINATED CARE MCAID COORDINATED CARE MCAID 180.35 85.07 999999999 165.36 201.4 percent of total billed charges LEVETIRACETAM 3018017701_1 CDM 301 RC 80177 HCPCS outpatient 212 159 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 180.35 85.07 999999999 165.36 201.4 percent of total billed charges LEVETIRACETAM 3018017701_1 CDM 301 RC 80177 HCPCS outpatient 212 159 MOLINA MCAID MOLINA MCAID 176.81 83.4 999999999 165.36 201.4 percent of total billed charges LEVETIRACETAM 3018017701_1 CDM 301 RC 80177 HCPCS outpatient 212 159 MOLINA MCR ADV MOLINA MCR ADV 188.68 89 999999999 165.36 201.4 percent of total billed charges LEVETIRACETAM 3018017701_1 CDM 301 RC 80177 HCPCS outpatient 212 159 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 188.68 89 999999999 165.36 201.4 percent of total billed charges LEVETIRACETAM 3018017701_1 CDM 301 RC 80177 HCPCS outpatient 212 159 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 188.68 89 999999999 165.36 201.4 percent of total billed charges LEVETIRACETAM 3018017701_1 CDM 301 RC 80177 HCPCS outpatient 212 159 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 190.8 90 999999999 165.36 201.4 percent of total billed charges LEVETIRACETAM 3018017701_1 CDM 301 RC 80177 HCPCS outpatient 212 159 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 201.4 95 999999999 165.36 201.4 percent of total billed charges LEVETIRACETAM 3018017701_1 CDM 301 RC 80177 HCPCS outpatient 212 159 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 201.4 95 999999999 165.36 201.4 percent of total billed charges LEVETIRACETAM 3018017701_1 CDM 301 RC 80177 HCPCS outpatient 212 159 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 188.68 89 999999999 165.36 201.4 percent of total billed charges LEVETIRACETAM 3018017701_1 CDM 301 RC 80177 HCPCS outpatient 212 159 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 186.56 88 999999999 165.36 201.4 percent of total billed charges LEVETIRACETAM 3018017701_1 CDM 301 RC 80177 HCPCS outpatient 212 159 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 188.68 89 999999999 165.36 201.4 percent of total billed charges LITHIUM 3018017801_1 CDM 301 RC 80178 HCPCS outpatient 77 57.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 69.3 90 999999999 60.06 73.15 percent of total billed charges LITHIUM 3018017801_1 CDM 301 RC 80178 HCPCS outpatient 77 57.75 AETNA MCR ADV AETNA MCR ADV 60.06 78 999999999 60.06 73.15 percent of total billed charges LITHIUM 3018017801_1 CDM 301 RC 80178 HCPCS outpatient 77 57.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 67.43 87.57 999999999 60.06 73.15 percent of total billed charges LITHIUM 3018017801_1 CDM 301 RC 80178 HCPCS outpatient 77 57.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 65.5 85.07 999999999 60.06 73.15 percent of total billed charges LITHIUM 3018017801_1 CDM 301 RC 80178 HCPCS outpatient 77 57.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 65.5 85.07 999999999 60.06 73.15 percent of total billed charges LITHIUM 3018017801_1 CDM 301 RC 80178 HCPCS outpatient 77 57.75 MOLINA MCAID MOLINA MCAID 64.22 83.4 999999999 60.06 73.15 percent of total billed charges LITHIUM 3018017801_1 CDM 301 RC 80178 HCPCS outpatient 77 57.75 MOLINA MCR ADV MOLINA MCR ADV 68.53 89 999999999 60.06 73.15 percent of total billed charges LITHIUM 3018017801_1 CDM 301 RC 80178 HCPCS outpatient 77 57.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 68.53 89 999999999 60.06 73.15 percent of total billed charges LITHIUM 3018017801_1 CDM 301 RC 80178 HCPCS outpatient 77 57.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 68.53 89 999999999 60.06 73.15 percent of total billed charges LITHIUM 3018017801_1 CDM 301 RC 80178 HCPCS outpatient 77 57.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 69.3 90 999999999 60.06 73.15 percent of total billed charges LITHIUM 3018017801_1 CDM 301 RC 80178 HCPCS outpatient 77 57.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 73.15 95 999999999 60.06 73.15 percent of total billed charges LITHIUM 3018017801_1 CDM 301 RC 80178 HCPCS outpatient 77 57.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 73.15 95 999999999 60.06 73.15 percent of total billed charges LITHIUM 3018017801_1 CDM 301 RC 80178 HCPCS outpatient 77 57.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 68.53 89 999999999 60.06 73.15 percent of total billed charges LITHIUM 3018017801_1 CDM 301 RC 80178 HCPCS outpatient 77 57.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 67.76 88 999999999 60.06 73.15 percent of total billed charges LITHIUM 3018017801_1 CDM 301 RC 80178 HCPCS outpatient 77 57.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 68.53 89 999999999 60.06 73.15 percent of total billed charges SALICYLATE 3018017901_1 CDM 301 RC 80179 HCPCS outpatient 162 121.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 145.8 90 999999999 126.36 153.9 percent of total billed charges SALICYLATE 3018017901_1 CDM 301 RC 80179 HCPCS outpatient 162 121.5 AETNA MCR ADV AETNA MCR ADV 126.36 78 999999999 126.36 153.9 percent of total billed charges SALICYLATE 3018017901_1 CDM 301 RC 80179 HCPCS outpatient 162 121.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 141.86 87.57 999999999 126.36 153.9 percent of total billed charges SALICYLATE 3018017901_1 CDM 301 RC 80179 HCPCS outpatient 162 121.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 137.81 85.07 999999999 126.36 153.9 percent of total billed charges SALICYLATE 3018017901_1 CDM 301 RC 80179 HCPCS outpatient 162 121.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 137.81 85.07 999999999 126.36 153.9 percent of total billed charges SALICYLATE 3018017901_1 CDM 301 RC 80179 HCPCS outpatient 162 121.5 MOLINA MCAID MOLINA MCAID 135.11 83.4 999999999 126.36 153.9 percent of total billed charges SALICYLATE 3018017901_1 CDM 301 RC 80179 HCPCS outpatient 162 121.5 MOLINA MCR ADV MOLINA MCR ADV 144.18 89 999999999 126.36 153.9 percent of total billed charges SALICYLATE 3018017901_1 CDM 301 RC 80179 HCPCS outpatient 162 121.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 144.18 89 999999999 126.36 153.9 percent of total billed charges SALICYLATE 3018017901_1 CDM 301 RC 80179 HCPCS outpatient 162 121.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 144.18 89 999999999 126.36 153.9 percent of total billed charges SALICYLATE 3018017901_1 CDM 301 RC 80179 HCPCS outpatient 162 121.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 145.8 90 999999999 126.36 153.9 percent of total billed charges SALICYLATE 3018017901_1 CDM 301 RC 80179 HCPCS outpatient 162 121.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 153.9 95 999999999 126.36 153.9 percent of total billed charges SALICYLATE 3018017901_1 CDM 301 RC 80179 HCPCS outpatient 162 121.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 153.9 95 999999999 126.36 153.9 percent of total billed charges SALICYLATE 3018017901_1 CDM 301 RC 80179 HCPCS outpatient 162 121.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 144.18 89 999999999 126.36 153.9 percent of total billed charges SALICYLATE 3018017901_1 CDM 301 RC 80179 HCPCS outpatient 162 121.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 142.56 88 999999999 126.36 153.9 percent of total billed charges SALICYLATE 3018017901_1 CDM 301 RC 80179 HCPCS outpatient 162 121.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 144.18 89 999999999 126.36 153.9 percent of total billed charges PHENYTOIN; TOTAL 3018018501_1 CDM 301 RC 80185 HCPCS outpatient 127 95.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 114.3 90 999999999 99.06 120.65 percent of total billed charges PHENYTOIN; TOTAL 3018018501_1 CDM 301 RC 80185 HCPCS outpatient 127 95.25 AETNA MCR ADV AETNA MCR ADV 99.06 78 999999999 99.06 120.65 percent of total billed charges PHENYTOIN; TOTAL 3018018501_1 CDM 301 RC 80185 HCPCS outpatient 127 95.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 111.21 87.57 999999999 99.06 120.65 percent of total billed charges PHENYTOIN; TOTAL 3018018501_1 CDM 301 RC 80185 HCPCS outpatient 127 95.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 108.04 85.07 999999999 99.06 120.65 percent of total billed charges PHENYTOIN; TOTAL 3018018501_1 CDM 301 RC 80185 HCPCS outpatient 127 95.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 108.04 85.07 999999999 99.06 120.65 percent of total billed charges PHENYTOIN; TOTAL 3018018501_1 CDM 301 RC 80185 HCPCS outpatient 127 95.25 MOLINA MCAID MOLINA MCAID 105.92 83.4 999999999 99.06 120.65 percent of total billed charges PHENYTOIN; TOTAL 3018018501_1 CDM 301 RC 80185 HCPCS outpatient 127 95.25 MOLINA MCR ADV MOLINA MCR ADV 113.03 89 999999999 99.06 120.65 percent of total billed charges PHENYTOIN; TOTAL 3018018501_1 CDM 301 RC 80185 HCPCS outpatient 127 95.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 113.03 89 999999999 99.06 120.65 percent of total billed charges PHENYTOIN; TOTAL 3018018501_1 CDM 301 RC 80185 HCPCS outpatient 127 95.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 113.03 89 999999999 99.06 120.65 percent of total billed charges PHENYTOIN; TOTAL 3018018501_1 CDM 301 RC 80185 HCPCS outpatient 127 95.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 114.3 90 999999999 99.06 120.65 percent of total billed charges PHENYTOIN; TOTAL 3018018501_1 CDM 301 RC 80185 HCPCS outpatient 127 95.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 120.65 95 999999999 99.06 120.65 percent of total billed charges PHENYTOIN; TOTAL 3018018501_1 CDM 301 RC 80185 HCPCS outpatient 127 95.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 120.65 95 999999999 99.06 120.65 percent of total billed charges PHENYTOIN; TOTAL 3018018501_1 CDM 301 RC 80185 HCPCS outpatient 127 95.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 113.03 89 999999999 99.06 120.65 percent of total billed charges PHENYTOIN; TOTAL 3018018501_1 CDM 301 RC 80185 HCPCS outpatient 127 95.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 111.76 88 999999999 99.06 120.65 percent of total billed charges PHENYTOIN; TOTAL 3018018501_1 CDM 301 RC 80185 HCPCS outpatient 127 95.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 113.03 89 999999999 99.06 120.65 percent of total billed charges TACROLIMUS 3018019701_1 CDM 301 RC 80197 HCPCS outpatient 200 150 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 180 90 999999999 156 190 percent of total billed charges TACROLIMUS 3018019701_1 CDM 301 RC 80197 HCPCS outpatient 200 150 AETNA MCR ADV AETNA MCR ADV 156 78 999999999 156 190 percent of total billed charges TACROLIMUS 3018019701_1 CDM 301 RC 80197 HCPCS outpatient 200 150 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 175.14 87.57 999999999 156 190 percent of total billed charges TACROLIMUS 3018019701_1 CDM 301 RC 80197 HCPCS outpatient 200 150 COORDINATED CARE MCAID COORDINATED CARE MCAID 170.14 85.07 999999999 156 190 percent of total billed charges TACROLIMUS 3018019701_1 CDM 301 RC 80197 HCPCS outpatient 200 150 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 170.14 85.07 999999999 156 190 percent of total billed charges TACROLIMUS 3018019701_1 CDM 301 RC 80197 HCPCS outpatient 200 150 MOLINA MCAID MOLINA MCAID 166.8 83.4 999999999 156 190 percent of total billed charges TACROLIMUS 3018019701_1 CDM 301 RC 80197 HCPCS outpatient 200 150 MOLINA MCR ADV MOLINA MCR ADV 178 89 999999999 156 190 percent of total billed charges TACROLIMUS 3018019701_1 CDM 301 RC 80197 HCPCS outpatient 200 150 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 178 89 999999999 156 190 percent of total billed charges TACROLIMUS 3018019701_1 CDM 301 RC 80197 HCPCS outpatient 200 150 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 178 89 999999999 156 190 percent of total billed charges TACROLIMUS 3018019701_1 CDM 301 RC 80197 HCPCS outpatient 200 150 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 180 90 999999999 156 190 percent of total billed charges TACROLIMUS 3018019701_1 CDM 301 RC 80197 HCPCS outpatient 200 150 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 190 95 999999999 156 190 percent of total billed charges TACROLIMUS 3018019701_1 CDM 301 RC 80197 HCPCS outpatient 200 150 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 190 95 999999999 156 190 percent of total billed charges TACROLIMUS 3018019701_1 CDM 301 RC 80197 HCPCS outpatient 200 150 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 178 89 999999999 156 190 percent of total billed charges TACROLIMUS 3018019701_1 CDM 301 RC 80197 HCPCS outpatient 200 150 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 176 88 999999999 156 190 percent of total billed charges TACROLIMUS 3018019701_1 CDM 301 RC 80197 HCPCS outpatient 200 150 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 178 89 999999999 156 190 percent of total billed charges VANCOMYCIN 3018020201_1 CDM 301 RC 80202 HCPCS outpatient 172 129 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 154.8 90 999999999 134.16 163.4 percent of total billed charges VANCOMYCIN 3018020201_1 CDM 301 RC 80202 HCPCS outpatient 172 129 AETNA MCR ADV AETNA MCR ADV 134.16 78 999999999 134.16 163.4 percent of total billed charges VANCOMYCIN 3018020201_1 CDM 301 RC 80202 HCPCS outpatient 172 129 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 150.62 87.57 999999999 134.16 163.4 percent of total billed charges VANCOMYCIN 3018020201_1 CDM 301 RC 80202 HCPCS outpatient 172 129 COORDINATED CARE MCAID COORDINATED CARE MCAID 146.32 85.07 999999999 134.16 163.4 percent of total billed charges VANCOMYCIN 3018020201_1 CDM 301 RC 80202 HCPCS outpatient 172 129 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 146.32 85.07 999999999 134.16 163.4 percent of total billed charges VANCOMYCIN 3018020201_1 CDM 301 RC 80202 HCPCS outpatient 172 129 MOLINA MCAID MOLINA MCAID 143.45 83.4 999999999 134.16 163.4 percent of total billed charges VANCOMYCIN 3018020201_1 CDM 301 RC 80202 HCPCS outpatient 172 129 MOLINA MCR ADV MOLINA MCR ADV 153.08 89 999999999 134.16 163.4 percent of total billed charges VANCOMYCIN 3018020201_1 CDM 301 RC 80202 HCPCS outpatient 172 129 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 153.08 89 999999999 134.16 163.4 percent of total billed charges VANCOMYCIN 3018020201_1 CDM 301 RC 80202 HCPCS outpatient 172 129 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 153.08 89 999999999 134.16 163.4 percent of total billed charges VANCOMYCIN 3018020201_1 CDM 301 RC 80202 HCPCS outpatient 172 129 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 154.8 90 999999999 134.16 163.4 percent of total billed charges VANCOMYCIN 3018020201_1 CDM 301 RC 80202 HCPCS outpatient 172 129 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 163.4 95 999999999 134.16 163.4 percent of total billed charges VANCOMYCIN 3018020201_1 CDM 301 RC 80202 HCPCS outpatient 172 129 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 163.4 95 999999999 134.16 163.4 percent of total billed charges VANCOMYCIN 3018020201_1 CDM 301 RC 80202 HCPCS outpatient 172 129 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 153.08 89 999999999 134.16 163.4 percent of total billed charges VANCOMYCIN 3018020201_1 CDM 301 RC 80202 HCPCS outpatient 172 129 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 151.36 88 999999999 134.16 163.4 percent of total billed charges VANCOMYCIN 3018020201_1 CDM 301 RC 80202 HCPCS outpatient 172 129 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 153.08 89 999999999 134.16 163.4 percent of total billed charges "QUANTITATION OF THERAPEUTIC DRUG, NOT ELSEWHERE SPECIFIED" 3018029910_1 CDM 301 RC 80299 HCPCS outpatient 166 124.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 149.4 90 999999999 129.48 157.7 percent of total billed charges "QUANTITATION OF THERAPEUTIC DRUG, NOT ELSEWHERE SPECIFIED" 3018029910_1 CDM 301 RC 80299 HCPCS outpatient 166 124.5 AETNA MCR ADV AETNA MCR ADV 129.48 78 999999999 129.48 157.7 percent of total billed charges "QUANTITATION OF THERAPEUTIC DRUG, NOT ELSEWHERE SPECIFIED" 3018029910_1 CDM 301 RC 80299 HCPCS outpatient 166 124.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 145.37 87.57 999999999 129.48 157.7 percent of total billed charges "QUANTITATION OF THERAPEUTIC DRUG, NOT ELSEWHERE SPECIFIED" 3018029910_1 CDM 301 RC 80299 HCPCS outpatient 166 124.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 141.22 85.07 999999999 129.48 157.7 percent of total billed charges "QUANTITATION OF THERAPEUTIC DRUG, NOT ELSEWHERE SPECIFIED" 3018029910_1 CDM 301 RC 80299 HCPCS outpatient 166 124.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 141.22 85.07 999999999 129.48 157.7 percent of total billed charges "QUANTITATION OF THERAPEUTIC DRUG, NOT ELSEWHERE SPECIFIED" 3018029910_1 CDM 301 RC 80299 HCPCS outpatient 166 124.5 MOLINA MCAID MOLINA MCAID 138.44 83.4 999999999 129.48 157.7 percent of total billed charges "QUANTITATION OF THERAPEUTIC DRUG, NOT ELSEWHERE SPECIFIED" 3018029910_1 CDM 301 RC 80299 HCPCS outpatient 166 124.5 MOLINA MCR ADV MOLINA MCR ADV 147.74 89 999999999 129.48 157.7 percent of total billed charges "QUANTITATION OF THERAPEUTIC DRUG, NOT ELSEWHERE SPECIFIED" 3018029910_1 CDM 301 RC 80299 HCPCS outpatient 166 124.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 147.74 89 999999999 129.48 157.7 percent of total billed charges "QUANTITATION OF THERAPEUTIC DRUG, NOT ELSEWHERE SPECIFIED" 3018029910_1 CDM 301 RC 80299 HCPCS outpatient 166 124.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 147.74 89 999999999 129.48 157.7 percent of total billed charges "QUANTITATION OF THERAPEUTIC DRUG, NOT ELSEWHERE SPECIFIED" 3018029910_1 CDM 301 RC 80299 HCPCS outpatient 166 124.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 149.4 90 999999999 129.48 157.7 percent of total billed charges "QUANTITATION OF THERAPEUTIC DRUG, NOT ELSEWHERE SPECIFIED" 3018029910_1 CDM 301 RC 80299 HCPCS outpatient 166 124.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 157.7 95 999999999 129.48 157.7 percent of total billed charges "QUANTITATION OF THERAPEUTIC DRUG, NOT ELSEWHERE SPECIFIED" 3018029910_1 CDM 301 RC 80299 HCPCS outpatient 166 124.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 157.7 95 999999999 129.48 157.7 percent of total billed charges "QUANTITATION OF THERAPEUTIC DRUG, NOT ELSEWHERE SPECIFIED" 3018029910_1 CDM 301 RC 80299 HCPCS outpatient 166 124.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 147.74 89 999999999 129.48 157.7 percent of total billed charges "QUANTITATION OF THERAPEUTIC DRUG, NOT ELSEWHERE SPECIFIED" 3018029910_1 CDM 301 RC 80299 HCPCS outpatient 166 124.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 146.08 88 999999999 129.48 157.7 percent of total billed charges "QUANTITATION OF THERAPEUTIC DRUG, NOT ELSEWHERE SPECIFIED" 3018029910_1 CDM 301 RC 80299 HCPCS outpatient 166 124.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 147.74 89 999999999 129.48 157.7 percent of total billed charges "DRUG TEST(S), PRESUMPTIVE, ANY NUMBER OF DRUG CLASSES, ANY NUMBER OF DEVICES OR PROCEDURES; CAPABLE OF BEING READ BY DIRECT OPTICAL OBSERVATION ONLY (EG, UTILIZING IMMUNOASSAY [EG, DIPSTICKS, CUPS, CARDS, OR CARTRIDGES]), INCLUDES SAMPLE VALIDATION WHEN PERFORMED, PER DATE OF SERVICE" 3018030503_1 CDM 301 RC 80305 HCPCS outpatient 44 33 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 39.6 90 999999999 34.32 41.8 percent of total billed charges "DRUG TEST(S), PRESUMPTIVE, ANY NUMBER OF DRUG CLASSES, ANY NUMBER OF DEVICES OR PROCEDURES; CAPABLE OF BEING READ BY DIRECT OPTICAL OBSERVATION ONLY (EG, UTILIZING IMMUNOASSAY [EG, DIPSTICKS, CUPS, CARDS, OR CARTRIDGES]), INCLUDES SAMPLE VALIDATION WHEN PERFORMED, PER DATE OF SERVICE" 3018030503_1 CDM 301 RC 80305 HCPCS outpatient 44 33 AETNA MCR ADV AETNA MCR ADV 34.32 78 999999999 34.32 41.8 percent of total billed charges "DRUG TEST(S), PRESUMPTIVE, ANY NUMBER OF DRUG CLASSES, ANY NUMBER OF DEVICES OR PROCEDURES; CAPABLE OF BEING READ BY DIRECT OPTICAL OBSERVATION ONLY (EG, UTILIZING IMMUNOASSAY [EG, DIPSTICKS, CUPS, CARDS, OR CARTRIDGES]), INCLUDES SAMPLE VALIDATION WHEN PERFORMED, PER DATE OF SERVICE" 3018030503_1 CDM 301 RC 80305 HCPCS outpatient 44 33 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 38.53 87.57 999999999 34.32 41.8 percent of total billed charges "DRUG TEST(S), PRESUMPTIVE, ANY NUMBER OF DRUG CLASSES, ANY NUMBER OF DEVICES OR PROCEDURES; CAPABLE OF BEING READ BY DIRECT OPTICAL OBSERVATION ONLY (EG, UTILIZING IMMUNOASSAY [EG, DIPSTICKS, CUPS, CARDS, OR CARTRIDGES]), INCLUDES SAMPLE VALIDATION WHEN PERFORMED, PER DATE OF SERVICE" 3018030503_1 CDM 301 RC 80305 HCPCS outpatient 44 33 COORDINATED CARE MCAID COORDINATED CARE MCAID 37.43 85.07 999999999 34.32 41.8 percent of total billed charges "DRUG TEST(S), PRESUMPTIVE, ANY NUMBER OF DRUG CLASSES, ANY NUMBER OF DEVICES OR PROCEDURES; CAPABLE OF BEING READ BY DIRECT OPTICAL OBSERVATION ONLY (EG, UTILIZING IMMUNOASSAY [EG, DIPSTICKS, CUPS, CARDS, OR CARTRIDGES]), INCLUDES SAMPLE VALIDATION WHEN PERFORMED, PER DATE OF SERVICE" 3018030503_1 CDM 301 RC 80305 HCPCS outpatient 44 33 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 37.43 85.07 999999999 34.32 41.8 percent of total billed charges "DRUG TEST(S), PRESUMPTIVE, ANY NUMBER OF DRUG CLASSES, ANY NUMBER OF DEVICES OR PROCEDURES; CAPABLE OF BEING READ BY DIRECT OPTICAL OBSERVATION ONLY (EG, UTILIZING IMMUNOASSAY [EG, DIPSTICKS, CUPS, CARDS, OR CARTRIDGES]), INCLUDES SAMPLE VALIDATION WHEN PERFORMED, PER DATE OF SERVICE" 3018030503_1 CDM 301 RC 80305 HCPCS outpatient 44 33 MOLINA MCAID MOLINA MCAID 36.7 83.4 999999999 34.32 41.8 percent of total billed charges "DRUG TEST(S), PRESUMPTIVE, ANY NUMBER OF DRUG CLASSES, ANY NUMBER OF DEVICES OR PROCEDURES; CAPABLE OF BEING READ BY DIRECT OPTICAL OBSERVATION ONLY (EG, UTILIZING IMMUNOASSAY [EG, DIPSTICKS, CUPS, CARDS, OR CARTRIDGES]), INCLUDES SAMPLE VALIDATION WHEN PERFORMED, PER DATE OF SERVICE" 3018030503_1 CDM 301 RC 80305 HCPCS outpatient 44 33 MOLINA MCR ADV MOLINA MCR ADV 39.16 89 999999999 34.32 41.8 percent of total billed charges "DRUG TEST(S), PRESUMPTIVE, ANY NUMBER OF DRUG CLASSES, ANY NUMBER OF DEVICES OR PROCEDURES; CAPABLE OF BEING READ BY DIRECT OPTICAL OBSERVATION ONLY (EG, UTILIZING IMMUNOASSAY [EG, DIPSTICKS, CUPS, CARDS, OR CARTRIDGES]), INCLUDES SAMPLE VALIDATION WHEN PERFORMED, PER DATE OF SERVICE" 3018030503_1 CDM 301 RC 80305 HCPCS outpatient 44 33 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 39.16 89 999999999 34.32 41.8 percent of total billed charges "DRUG TEST(S), PRESUMPTIVE, ANY NUMBER OF DRUG CLASSES, ANY NUMBER OF DEVICES OR PROCEDURES; CAPABLE OF BEING READ BY DIRECT OPTICAL OBSERVATION ONLY (EG, UTILIZING IMMUNOASSAY [EG, DIPSTICKS, CUPS, CARDS, OR CARTRIDGES]), INCLUDES SAMPLE VALIDATION WHEN PERFORMED, PER DATE OF SERVICE" 3018030503_1 CDM 301 RC 80305 HCPCS outpatient 44 33 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 39.16 89 999999999 34.32 41.8 percent of total billed charges "DRUG TEST(S), PRESUMPTIVE, ANY NUMBER OF DRUG CLASSES, ANY NUMBER OF DEVICES OR PROCEDURES; CAPABLE OF BEING READ BY DIRECT OPTICAL OBSERVATION ONLY (EG, UTILIZING IMMUNOASSAY [EG, DIPSTICKS, CUPS, CARDS, OR CARTRIDGES]), INCLUDES SAMPLE VALIDATION WHEN PERFORMED, PER DATE OF SERVICE" 3018030503_1 CDM 301 RC 80305 HCPCS outpatient 44 33 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 39.6 90 999999999 34.32 41.8 percent of total billed charges "DRUG TEST(S), PRESUMPTIVE, ANY NUMBER OF DRUG CLASSES, ANY NUMBER OF DEVICES OR PROCEDURES; CAPABLE OF BEING READ BY DIRECT OPTICAL OBSERVATION ONLY (EG, UTILIZING IMMUNOASSAY [EG, DIPSTICKS, CUPS, CARDS, OR CARTRIDGES]), INCLUDES SAMPLE VALIDATION WHEN PERFORMED, PER DATE OF SERVICE" 3018030503_1 CDM 301 RC 80305 HCPCS outpatient 44 33 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 41.8 95 999999999 34.32 41.8 percent of total billed charges "DRUG TEST(S), PRESUMPTIVE, ANY NUMBER OF DRUG CLASSES, ANY NUMBER OF DEVICES OR PROCEDURES; CAPABLE OF BEING READ BY DIRECT OPTICAL OBSERVATION ONLY (EG, UTILIZING IMMUNOASSAY [EG, DIPSTICKS, CUPS, CARDS, OR CARTRIDGES]), INCLUDES SAMPLE VALIDATION WHEN PERFORMED, PER DATE OF SERVICE" 3018030503_1 CDM 301 RC 80305 HCPCS outpatient 44 33 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 41.8 95 999999999 34.32 41.8 percent of total billed charges "DRUG TEST(S), PRESUMPTIVE, ANY NUMBER OF DRUG CLASSES, ANY NUMBER OF DEVICES OR PROCEDURES; CAPABLE OF BEING READ BY DIRECT OPTICAL OBSERVATION ONLY (EG, UTILIZING IMMUNOASSAY [EG, DIPSTICKS, CUPS, CARDS, OR CARTRIDGES]), INCLUDES SAMPLE VALIDATION WHEN PERFORMED, PER DATE OF SERVICE" 3018030503_1 CDM 301 RC 80305 HCPCS outpatient 44 33 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 39.16 89 999999999 34.32 41.8 percent of total billed charges "DRUG TEST(S), PRESUMPTIVE, ANY NUMBER OF DRUG CLASSES, ANY NUMBER OF DEVICES OR PROCEDURES; CAPABLE OF BEING READ BY DIRECT OPTICAL OBSERVATION ONLY (EG, UTILIZING IMMUNOASSAY [EG, DIPSTICKS, CUPS, CARDS, OR CARTRIDGES]), INCLUDES SAMPLE VALIDATION WHEN PERFORMED, PER DATE OF SERVICE" 3018030503_1 CDM 301 RC 80305 HCPCS outpatient 44 33 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 38.72 88 999999999 34.32 41.8 percent of total billed charges "DRUG TEST(S), PRESUMPTIVE, ANY NUMBER OF DRUG CLASSES, ANY NUMBER OF DEVICES OR PROCEDURES; CAPABLE OF BEING READ BY DIRECT OPTICAL OBSERVATION ONLY (EG, UTILIZING IMMUNOASSAY [EG, DIPSTICKS, CUPS, CARDS, OR CARTRIDGES]), INCLUDES SAMPLE VALIDATION WHEN PERFORMED, PER DATE OF SERVICE" 3018030503_1 CDM 301 RC 80305 HCPCS outpatient 44 33 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 39.16 89 999999999 34.32 41.8 percent of total billed charges "DRUG TEST(S), PRESUMPTIVE, ANY NUMBER OF DRUG CLASSES, ANY NUMBER OF DEVICES OR PROCEDURES; BY INSTRUMENT CHEMISTRY ANALYZERS (EG, UTILIZING IMMUNOASSAY [EG, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), CHROMATOGRAPHY (EG, GC, HPLC), AND MASS SPECTROMETRY EITHER WITH OR WITHOUT CHROMATOGRAPHY, (EG, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) INCLUDES SAMPLE VALIDATION WHEN PERFORMED, PER DATE OF SERVICE" 3018030701_1 CDM 301 RC 80307 HCPCS outpatient 260 195 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 221.18 85.07 999999999 202.8 247 percent of total billed charges "DRUG TEST(S), PRESUMPTIVE, ANY NUMBER OF DRUG CLASSES, ANY NUMBER OF DEVICES OR PROCEDURES; BY INSTRUMENT CHEMISTRY ANALYZERS (EG, UTILIZING IMMUNOASSAY [EG, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), CHROMATOGRAPHY (EG, GC, HPLC), AND MASS SPECTROMETRY EITHER WITH OR WITHOUT CHROMATOGRAPHY, (EG, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) INCLUDES SAMPLE VALIDATION WHEN PERFORMED, PER DATE OF SERVICE" 3018030701_1 CDM 301 RC 80307 HCPCS outpatient 260 195 MOLINA MCAID MOLINA MCAID 216.84 83.4 999999999 202.8 247 percent of total billed charges "DRUG TEST(S), PRESUMPTIVE, ANY NUMBER OF DRUG CLASSES, ANY NUMBER OF DEVICES OR PROCEDURES; BY INSTRUMENT CHEMISTRY ANALYZERS (EG, UTILIZING IMMUNOASSAY [EG, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), CHROMATOGRAPHY (EG, GC, HPLC), AND MASS SPECTROMETRY EITHER WITH OR WITHOUT CHROMATOGRAPHY, (EG, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) INCLUDES SAMPLE VALIDATION WHEN PERFORMED, PER DATE OF SERVICE" 3018030701_1 CDM 301 RC 80307 HCPCS outpatient 260 195 MOLINA MCR ADV MOLINA MCR ADV 231.4 89 999999999 202.8 247 percent of total billed charges "DRUG TEST(S), PRESUMPTIVE, ANY NUMBER OF DRUG CLASSES, ANY NUMBER OF DEVICES OR PROCEDURES; BY INSTRUMENT CHEMISTRY ANALYZERS (EG, UTILIZING IMMUNOASSAY [EG, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), CHROMATOGRAPHY (EG, GC, HPLC), AND MASS SPECTROMETRY EITHER WITH OR WITHOUT CHROMATOGRAPHY, (EG, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) INCLUDES SAMPLE VALIDATION WHEN PERFORMED, PER DATE OF SERVICE" 3018030701_1 CDM 301 RC 80307 HCPCS outpatient 260 195 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 231.4 89 999999999 202.8 247 percent of total billed charges "DRUG TEST(S), PRESUMPTIVE, ANY NUMBER OF DRUG CLASSES, ANY NUMBER OF DEVICES OR PROCEDURES; BY INSTRUMENT CHEMISTRY ANALYZERS (EG, UTILIZING IMMUNOASSAY [EG, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), CHROMATOGRAPHY (EG, GC, HPLC), AND MASS SPECTROMETRY EITHER WITH OR WITHOUT CHROMATOGRAPHY, (EG, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) INCLUDES SAMPLE VALIDATION WHEN PERFORMED, PER DATE OF SERVICE" 3018030701_1 CDM 301 RC 80307 HCPCS outpatient 260 195 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 231.4 89 999999999 202.8 247 percent of total billed charges "DRUG TEST(S), PRESUMPTIVE, ANY NUMBER OF DRUG CLASSES, ANY NUMBER OF DEVICES OR PROCEDURES; BY INSTRUMENT CHEMISTRY ANALYZERS (EG, UTILIZING IMMUNOASSAY [EG, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), CHROMATOGRAPHY (EG, GC, HPLC), AND MASS SPECTROMETRY EITHER WITH OR WITHOUT CHROMATOGRAPHY, (EG, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) INCLUDES SAMPLE VALIDATION WHEN PERFORMED, PER DATE OF SERVICE" 3018030701_1 CDM 301 RC 80307 HCPCS outpatient 260 195 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 234 90 999999999 202.8 247 percent of total billed charges "DRUG TEST(S), PRESUMPTIVE, ANY NUMBER OF DRUG CLASSES, ANY NUMBER OF DEVICES OR PROCEDURES; BY INSTRUMENT CHEMISTRY ANALYZERS (EG, UTILIZING IMMUNOASSAY [EG, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), CHROMATOGRAPHY (EG, GC, HPLC), AND MASS SPECTROMETRY EITHER WITH OR WITHOUT CHROMATOGRAPHY, (EG, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) INCLUDES SAMPLE VALIDATION WHEN PERFORMED, PER DATE OF SERVICE" 3018030701_1 CDM 301 RC 80307 HCPCS outpatient 260 195 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 247 95 999999999 202.8 247 percent of total billed charges "DRUG TEST(S), PRESUMPTIVE, ANY NUMBER OF DRUG CLASSES, ANY NUMBER OF DEVICES OR PROCEDURES; BY INSTRUMENT CHEMISTRY ANALYZERS (EG, UTILIZING IMMUNOASSAY [EG, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), CHROMATOGRAPHY (EG, GC, HPLC), AND MASS SPECTROMETRY EITHER WITH OR WITHOUT CHROMATOGRAPHY, (EG, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) INCLUDES SAMPLE VALIDATION WHEN PERFORMED, PER DATE OF SERVICE" 3018030701_1 CDM 301 RC 80307 HCPCS outpatient 260 195 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 247 95 999999999 202.8 247 percent of total billed charges "DRUG TEST(S), PRESUMPTIVE, ANY NUMBER OF DRUG CLASSES, ANY NUMBER OF DEVICES OR PROCEDURES; BY INSTRUMENT CHEMISTRY ANALYZERS (EG, UTILIZING IMMUNOASSAY [EG, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), CHROMATOGRAPHY (EG, GC, HPLC), AND MASS SPECTROMETRY EITHER WITH OR WITHOUT CHROMATOGRAPHY, (EG, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) INCLUDES SAMPLE VALIDATION WHEN PERFORMED, PER DATE OF SERVICE" 3018030701_1 CDM 301 RC 80307 HCPCS outpatient 260 195 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 231.4 89 999999999 202.8 247 percent of total billed charges "DRUG TEST(S), PRESUMPTIVE, ANY NUMBER OF DRUG CLASSES, ANY NUMBER OF DEVICES OR PROCEDURES; BY INSTRUMENT CHEMISTRY ANALYZERS (EG, UTILIZING IMMUNOASSAY [EG, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), CHROMATOGRAPHY (EG, GC, HPLC), AND MASS SPECTROMETRY EITHER WITH OR WITHOUT CHROMATOGRAPHY, (EG, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) INCLUDES SAMPLE VALIDATION WHEN PERFORMED, PER DATE OF SERVICE" 3018030701_1 CDM 301 RC 80307 HCPCS outpatient 260 195 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 228.8 88 999999999 202.8 247 percent of total billed charges "DRUG TEST(S), PRESUMPTIVE, ANY NUMBER OF DRUG CLASSES, ANY NUMBER OF DEVICES OR PROCEDURES; BY INSTRUMENT CHEMISTRY ANALYZERS (EG, UTILIZING IMMUNOASSAY [EG, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), CHROMATOGRAPHY (EG, GC, HPLC), AND MASS SPECTROMETRY EITHER WITH OR WITHOUT CHROMATOGRAPHY, (EG, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) INCLUDES SAMPLE VALIDATION WHEN PERFORMED, PER DATE OF SERVICE" 3018030701_1 CDM 301 RC 80307 HCPCS outpatient 260 195 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 231.4 89 999999999 202.8 247 percent of total billed charges "DRUG TEST(S), PRESUMPTIVE, ANY NUMBER OF DRUG CLASSES, ANY NUMBER OF DEVICES OR PROCEDURES; BY INSTRUMENT CHEMISTRY ANALYZERS (EG, UTILIZING IMMUNOASSAY [EG, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), CHROMATOGRAPHY (EG, GC, HPLC), AND MASS SPECTROMETRY EITHER WITH OR WITHOUT CHROMATOGRAPHY, (EG, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) INCLUDES SAMPLE VALIDATION WHEN PERFORMED, PER DATE OF SERVICE" 3018030701_1 CDM 301 RC 80307 HCPCS outpatient 260 195 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 234 90 999999999 202.8 247 percent of total billed charges "DRUG TEST(S), PRESUMPTIVE, ANY NUMBER OF DRUG CLASSES, ANY NUMBER OF DEVICES OR PROCEDURES; BY INSTRUMENT CHEMISTRY ANALYZERS (EG, UTILIZING IMMUNOASSAY [EG, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), CHROMATOGRAPHY (EG, GC, HPLC), AND MASS SPECTROMETRY EITHER WITH OR WITHOUT CHROMATOGRAPHY, (EG, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) INCLUDES SAMPLE VALIDATION WHEN PERFORMED, PER DATE OF SERVICE" 3018030701_1 CDM 301 RC 80307 HCPCS outpatient 260 195 AETNA MCR ADV AETNA MCR ADV 202.8 78 999999999 202.8 247 percent of total billed charges "DRUG TEST(S), PRESUMPTIVE, ANY NUMBER OF DRUG CLASSES, ANY NUMBER OF DEVICES OR PROCEDURES; BY INSTRUMENT CHEMISTRY ANALYZERS (EG, UTILIZING IMMUNOASSAY [EG, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), CHROMATOGRAPHY (EG, GC, HPLC), AND MASS SPECTROMETRY EITHER WITH OR WITHOUT CHROMATOGRAPHY, (EG, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) INCLUDES SAMPLE VALIDATION WHEN PERFORMED, PER DATE OF SERVICE" 3018030701_1 CDM 301 RC 80307 HCPCS outpatient 260 195 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 227.68 87.57 999999999 202.8 247 percent of total billed charges "DRUG TEST(S), PRESUMPTIVE, ANY NUMBER OF DRUG CLASSES, ANY NUMBER OF DEVICES OR PROCEDURES; BY INSTRUMENT CHEMISTRY ANALYZERS (EG, UTILIZING IMMUNOASSAY [EG, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), CHROMATOGRAPHY (EG, GC, HPLC), AND MASS SPECTROMETRY EITHER WITH OR WITHOUT CHROMATOGRAPHY, (EG, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) INCLUDES SAMPLE VALIDATION WHEN PERFORMED, PER DATE OF SERVICE" 3018030701_1 CDM 301 RC 80307 HCPCS outpatient 260 195 COORDINATED CARE MCAID COORDINATED CARE MCAID 221.18 85.07 999999999 202.8 247 percent of total billed charges ALCOHOLS 3018032001_1 CDM 301 RC 80320 HCPCS outpatient 155 116.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 139.5 90 999999999 120.9 147.25 percent of total billed charges ALCOHOLS 3018032001_1 CDM 301 RC 80320 HCPCS outpatient 155 116.25 AETNA MCR ADV AETNA MCR ADV 120.9 78 999999999 120.9 147.25 percent of total billed charges ALCOHOLS 3018032001_1 CDM 301 RC 80320 HCPCS outpatient 155 116.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 135.73 87.57 999999999 120.9 147.25 percent of total billed charges ALCOHOLS 3018032001_1 CDM 301 RC 80320 HCPCS outpatient 155 116.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 131.86 85.07 999999999 120.9 147.25 percent of total billed charges ALCOHOLS 3018032001_1 CDM 301 RC 80320 HCPCS outpatient 155 116.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 131.86 85.07 999999999 120.9 147.25 percent of total billed charges ALCOHOLS 3018032001_1 CDM 301 RC 80320 HCPCS outpatient 155 116.25 MOLINA MCAID MOLINA MCAID 129.27 83.4 999999999 120.9 147.25 percent of total billed charges ALCOHOLS 3018032001_1 CDM 301 RC 80320 HCPCS outpatient 155 116.25 MOLINA MCR ADV MOLINA MCR ADV 137.95 89 999999999 120.9 147.25 percent of total billed charges ALCOHOLS 3018032001_1 CDM 301 RC 80320 HCPCS outpatient 155 116.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 137.95 89 999999999 120.9 147.25 percent of total billed charges ALCOHOLS 3018032001_1 CDM 301 RC 80320 HCPCS outpatient 155 116.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 137.95 89 999999999 120.9 147.25 percent of total billed charges ALCOHOLS 3018032001_1 CDM 301 RC 80320 HCPCS outpatient 155 116.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 139.5 90 999999999 120.9 147.25 percent of total billed charges ALCOHOLS 3018032001_1 CDM 301 RC 80320 HCPCS outpatient 155 116.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 147.25 95 999999999 120.9 147.25 percent of total billed charges ALCOHOLS 3018032001_1 CDM 301 RC 80320 HCPCS outpatient 155 116.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 147.25 95 999999999 120.9 147.25 percent of total billed charges ALCOHOLS 3018032001_1 CDM 301 RC 80320 HCPCS outpatient 155 116.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 137.95 89 999999999 120.9 147.25 percent of total billed charges ALCOHOLS 3018032001_1 CDM 301 RC 80320 HCPCS outpatient 155 116.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 136.4 88 999999999 120.9 147.25 percent of total billed charges ALCOHOLS 3018032001_1 CDM 301 RC 80320 HCPCS outpatient 155 116.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 137.95 89 999999999 120.9 147.25 percent of total billed charges AMPHETAMINES; 1 OR 2 3018032402_1 CDM 301 RC 80324 HCPCS outpatient 191 143.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 171.9 90 999999999 148.98 181.45 percent of total billed charges AMPHETAMINES; 1 OR 2 3018032402_1 CDM 301 RC 80324 HCPCS outpatient 191 143.25 AETNA MCR ADV AETNA MCR ADV 148.98 78 999999999 148.98 181.45 percent of total billed charges AMPHETAMINES; 1 OR 2 3018032402_1 CDM 301 RC 80324 HCPCS outpatient 191 143.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 167.26 87.57 999999999 148.98 181.45 percent of total billed charges AMPHETAMINES; 1 OR 2 3018032402_1 CDM 301 RC 80324 HCPCS outpatient 191 143.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 162.48 85.07 999999999 148.98 181.45 percent of total billed charges AMPHETAMINES; 1 OR 2 3018032402_1 CDM 301 RC 80324 HCPCS outpatient 191 143.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 162.48 85.07 999999999 148.98 181.45 percent of total billed charges AMPHETAMINES; 1 OR 2 3018032402_1 CDM 301 RC 80324 HCPCS outpatient 191 143.25 MOLINA MCAID MOLINA MCAID 159.29 83.4 999999999 148.98 181.45 percent of total billed charges AMPHETAMINES; 1 OR 2 3018032402_1 CDM 301 RC 80324 HCPCS outpatient 191 143.25 MOLINA MCR ADV MOLINA MCR ADV 169.99 89 999999999 148.98 181.45 percent of total billed charges AMPHETAMINES; 1 OR 2 3018032402_1 CDM 301 RC 80324 HCPCS outpatient 191 143.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 169.99 89 999999999 148.98 181.45 percent of total billed charges AMPHETAMINES; 1 OR 2 3018032402_1 CDM 301 RC 80324 HCPCS outpatient 191 143.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 169.99 89 999999999 148.98 181.45 percent of total billed charges AMPHETAMINES; 1 OR 2 3018032402_1 CDM 301 RC 80324 HCPCS outpatient 191 143.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 171.9 90 999999999 148.98 181.45 percent of total billed charges AMPHETAMINES; 1 OR 2 3018032402_1 CDM 301 RC 80324 HCPCS outpatient 191 143.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 181.45 95 999999999 148.98 181.45 percent of total billed charges AMPHETAMINES; 1 OR 2 3018032402_1 CDM 301 RC 80324 HCPCS outpatient 191 143.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 181.45 95 999999999 148.98 181.45 percent of total billed charges AMPHETAMINES; 1 OR 2 3018032402_1 CDM 301 RC 80324 HCPCS outpatient 191 143.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 169.99 89 999999999 148.98 181.45 percent of total billed charges AMPHETAMINES; 1 OR 2 3018032402_1 CDM 301 RC 80324 HCPCS outpatient 191 143.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 168.08 88 999999999 148.98 181.45 percent of total billed charges AMPHETAMINES; 1 OR 2 3018032402_1 CDM 301 RC 80324 HCPCS outpatient 191 143.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 169.99 89 999999999 148.98 181.45 percent of total billed charges BENZODIAZEPINES; 13 OR MORE 3018034701_1 CDM 301 RC 80347 HCPCS outpatient 125 93.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 112.5 90 999999999 97.5 118.75 percent of total billed charges BENZODIAZEPINES; 13 OR MORE 3018034701_1 CDM 301 RC 80347 HCPCS outpatient 125 93.75 AETNA MCR ADV AETNA MCR ADV 97.5 78 999999999 97.5 118.75 percent of total billed charges BENZODIAZEPINES; 13 OR MORE 3018034701_1 CDM 301 RC 80347 HCPCS outpatient 125 93.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 109.46 87.57 999999999 97.5 118.75 percent of total billed charges BENZODIAZEPINES; 13 OR MORE 3018034701_1 CDM 301 RC 80347 HCPCS outpatient 125 93.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 106.34 85.07 999999999 97.5 118.75 percent of total billed charges BENZODIAZEPINES; 13 OR MORE 3018034701_1 CDM 301 RC 80347 HCPCS outpatient 125 93.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 106.34 85.07 999999999 97.5 118.75 percent of total billed charges BENZODIAZEPINES; 13 OR MORE 3018034701_1 CDM 301 RC 80347 HCPCS outpatient 125 93.75 MOLINA MCAID MOLINA MCAID 104.25 83.4 999999999 97.5 118.75 percent of total billed charges BENZODIAZEPINES; 13 OR MORE 3018034701_1 CDM 301 RC 80347 HCPCS outpatient 125 93.75 MOLINA MCR ADV MOLINA MCR ADV 111.25 89 999999999 97.5 118.75 percent of total billed charges BENZODIAZEPINES; 13 OR MORE 3018034701_1 CDM 301 RC 80347 HCPCS outpatient 125 93.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 111.25 89 999999999 97.5 118.75 percent of total billed charges BENZODIAZEPINES; 13 OR MORE 3018034701_1 CDM 301 RC 80347 HCPCS outpatient 125 93.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 111.25 89 999999999 97.5 118.75 percent of total billed charges BENZODIAZEPINES; 13 OR MORE 3018034701_1 CDM 301 RC 80347 HCPCS outpatient 125 93.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 112.5 90 999999999 97.5 118.75 percent of total billed charges BENZODIAZEPINES; 13 OR MORE 3018034701_1 CDM 301 RC 80347 HCPCS outpatient 125 93.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 118.75 95 999999999 97.5 118.75 percent of total billed charges BENZODIAZEPINES; 13 OR MORE 3018034701_1 CDM 301 RC 80347 HCPCS outpatient 125 93.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 118.75 95 999999999 97.5 118.75 percent of total billed charges BENZODIAZEPINES; 13 OR MORE 3018034701_1 CDM 301 RC 80347 HCPCS outpatient 125 93.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 111.25 89 999999999 97.5 118.75 percent of total billed charges BENZODIAZEPINES; 13 OR MORE 3018034701_1 CDM 301 RC 80347 HCPCS outpatient 125 93.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 110 88 999999999 97.5 118.75 percent of total billed charges BENZODIAZEPINES; 13 OR MORE 3018034701_1 CDM 301 RC 80347 HCPCS outpatient 125 93.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 111.25 89 999999999 97.5 118.75 percent of total billed charges BUPRENORPHINE 3018034801_1 CDM 301 RC 80348 HCPCS outpatient 207 155.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 186.3 90 999999999 161.46 196.65 percent of total billed charges BUPRENORPHINE 3018034801_1 CDM 301 RC 80348 HCPCS outpatient 207 155.25 AETNA MCR ADV AETNA MCR ADV 161.46 78 999999999 161.46 196.65 percent of total billed charges BUPRENORPHINE 3018034801_1 CDM 301 RC 80348 HCPCS outpatient 207 155.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 181.27 87.57 999999999 161.46 196.65 percent of total billed charges BUPRENORPHINE 3018034801_1 CDM 301 RC 80348 HCPCS outpatient 207 155.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 176.09 85.07 999999999 161.46 196.65 percent of total billed charges BUPRENORPHINE 3018034801_1 CDM 301 RC 80348 HCPCS outpatient 207 155.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 176.09 85.07 999999999 161.46 196.65 percent of total billed charges BUPRENORPHINE 3018034801_1 CDM 301 RC 80348 HCPCS outpatient 207 155.25 MOLINA MCAID MOLINA MCAID 172.64 83.4 999999999 161.46 196.65 percent of total billed charges BUPRENORPHINE 3018034801_1 CDM 301 RC 80348 HCPCS outpatient 207 155.25 MOLINA MCR ADV MOLINA MCR ADV 184.23 89 999999999 161.46 196.65 percent of total billed charges BUPRENORPHINE 3018034801_1 CDM 301 RC 80348 HCPCS outpatient 207 155.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 184.23 89 999999999 161.46 196.65 percent of total billed charges BUPRENORPHINE 3018034801_1 CDM 301 RC 80348 HCPCS outpatient 207 155.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 184.23 89 999999999 161.46 196.65 percent of total billed charges BUPRENORPHINE 3018034801_1 CDM 301 RC 80348 HCPCS outpatient 207 155.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 186.3 90 999999999 161.46 196.65 percent of total billed charges BUPRENORPHINE 3018034801_1 CDM 301 RC 80348 HCPCS outpatient 207 155.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 196.65 95 999999999 161.46 196.65 percent of total billed charges BUPRENORPHINE 3018034801_1 CDM 301 RC 80348 HCPCS outpatient 207 155.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 196.65 95 999999999 161.46 196.65 percent of total billed charges BUPRENORPHINE 3018034801_1 CDM 301 RC 80348 HCPCS outpatient 207 155.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 184.23 89 999999999 161.46 196.65 percent of total billed charges BUPRENORPHINE 3018034801_1 CDM 301 RC 80348 HCPCS outpatient 207 155.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 182.16 88 999999999 161.46 196.65 percent of total billed charges BUPRENORPHINE 3018034801_1 CDM 301 RC 80348 HCPCS outpatient 207 155.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 184.23 89 999999999 161.46 196.65 percent of total billed charges COCAINE 3018035301_1 CDM 301 RC 80353 HCPCS outpatient 75 56.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 67.5 90 999999999 58.5 71.25 percent of total billed charges COCAINE 3018035301_1 CDM 301 RC 80353 HCPCS outpatient 75 56.25 AETNA MCR ADV AETNA MCR ADV 58.5 78 999999999 58.5 71.25 percent of total billed charges COCAINE 3018035301_1 CDM 301 RC 80353 HCPCS outpatient 75 56.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 65.68 87.57 999999999 58.5 71.25 percent of total billed charges COCAINE 3018035301_1 CDM 301 RC 80353 HCPCS outpatient 75 56.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 63.8 85.07 999999999 58.5 71.25 percent of total billed charges COCAINE 3018035301_1 CDM 301 RC 80353 HCPCS outpatient 75 56.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 63.8 85.07 999999999 58.5 71.25 percent of total billed charges COCAINE 3018035301_1 CDM 301 RC 80353 HCPCS outpatient 75 56.25 MOLINA MCAID MOLINA MCAID 62.55 83.4 999999999 58.5 71.25 percent of total billed charges COCAINE 3018035301_1 CDM 301 RC 80353 HCPCS outpatient 75 56.25 MOLINA MCR ADV MOLINA MCR ADV 66.75 89 999999999 58.5 71.25 percent of total billed charges COCAINE 3018035301_1 CDM 301 RC 80353 HCPCS outpatient 75 56.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 66.75 89 999999999 58.5 71.25 percent of total billed charges COCAINE 3018035301_1 CDM 301 RC 80353 HCPCS outpatient 75 56.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 66.75 89 999999999 58.5 71.25 percent of total billed charges COCAINE 3018035301_1 CDM 301 RC 80353 HCPCS outpatient 75 56.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 67.5 90 999999999 58.5 71.25 percent of total billed charges COCAINE 3018035301_1 CDM 301 RC 80353 HCPCS outpatient 75 56.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 71.25 95 999999999 58.5 71.25 percent of total billed charges COCAINE 3018035301_1 CDM 301 RC 80353 HCPCS outpatient 75 56.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 71.25 95 999999999 58.5 71.25 percent of total billed charges COCAINE 3018035301_1 CDM 301 RC 80353 HCPCS outpatient 75 56.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 66.75 89 999999999 58.5 71.25 percent of total billed charges COCAINE 3018035301_1 CDM 301 RC 80353 HCPCS outpatient 75 56.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 66 88 999999999 58.5 71.25 percent of total billed charges COCAINE 3018035301_1 CDM 301 RC 80353 HCPCS outpatient 75 56.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 66.75 89 999999999 58.5 71.25 percent of total billed charges FENTANYL 3018035401_1 CDM 301 RC 80354 HCPCS outpatient 130 97.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 117 90 999999999 101.4 123.5 percent of total billed charges FENTANYL 3018035401_1 CDM 301 RC 80354 HCPCS outpatient 130 97.5 AETNA MCR ADV AETNA MCR ADV 101.4 78 999999999 101.4 123.5 percent of total billed charges FENTANYL 3018035401_1 CDM 301 RC 80354 HCPCS outpatient 130 97.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 113.84 87.57 999999999 101.4 123.5 percent of total billed charges FENTANYL 3018035401_1 CDM 301 RC 80354 HCPCS outpatient 130 97.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 110.59 85.07 999999999 101.4 123.5 percent of total billed charges FENTANYL 3018035401_1 CDM 301 RC 80354 HCPCS outpatient 130 97.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 110.59 85.07 999999999 101.4 123.5 percent of total billed charges FENTANYL 3018035401_1 CDM 301 RC 80354 HCPCS outpatient 130 97.5 MOLINA MCAID MOLINA MCAID 108.42 83.4 999999999 101.4 123.5 percent of total billed charges FENTANYL 3018035401_1 CDM 301 RC 80354 HCPCS outpatient 130 97.5 MOLINA MCR ADV MOLINA MCR ADV 115.7 89 999999999 101.4 123.5 percent of total billed charges FENTANYL 3018035401_1 CDM 301 RC 80354 HCPCS outpatient 130 97.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 115.7 89 999999999 101.4 123.5 percent of total billed charges FENTANYL 3018035401_1 CDM 301 RC 80354 HCPCS outpatient 130 97.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 115.7 89 999999999 101.4 123.5 percent of total billed charges FENTANYL 3018035401_1 CDM 301 RC 80354 HCPCS outpatient 130 97.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 117 90 999999999 101.4 123.5 percent of total billed charges FENTANYL 3018035401_1 CDM 301 RC 80354 HCPCS outpatient 130 97.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 123.5 95 999999999 101.4 123.5 percent of total billed charges FENTANYL 3018035401_1 CDM 301 RC 80354 HCPCS outpatient 130 97.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 123.5 95 999999999 101.4 123.5 percent of total billed charges FENTANYL 3018035401_1 CDM 301 RC 80354 HCPCS outpatient 130 97.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 115.7 89 999999999 101.4 123.5 percent of total billed charges FENTANYL 3018035401_1 CDM 301 RC 80354 HCPCS outpatient 130 97.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 114.4 88 999999999 101.4 123.5 percent of total billed charges FENTANYL 3018035401_1 CDM 301 RC 80354 HCPCS outpatient 130 97.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 115.7 89 999999999 101.4 123.5 percent of total billed charges METHADONE 3018035801_1 CDM 301 RC 80358 HCPCS outpatient 111 83.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 99.9 90 999999999 86.58 105.45 percent of total billed charges METHADONE 3018035801_1 CDM 301 RC 80358 HCPCS outpatient 111 83.25 AETNA MCR ADV AETNA MCR ADV 86.58 78 999999999 86.58 105.45 percent of total billed charges METHADONE 3018035801_1 CDM 301 RC 80358 HCPCS outpatient 111 83.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 97.2 87.57 999999999 86.58 105.45 percent of total billed charges METHADONE 3018035801_1 CDM 301 RC 80358 HCPCS outpatient 111 83.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 94.43 85.07 999999999 86.58 105.45 percent of total billed charges METHADONE 3018035801_1 CDM 301 RC 80358 HCPCS outpatient 111 83.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 94.43 85.07 999999999 86.58 105.45 percent of total billed charges METHADONE 3018035801_1 CDM 301 RC 80358 HCPCS outpatient 111 83.25 MOLINA MCAID MOLINA MCAID 92.57 83.4 999999999 86.58 105.45 percent of total billed charges METHADONE 3018035801_1 CDM 301 RC 80358 HCPCS outpatient 111 83.25 MOLINA MCR ADV MOLINA MCR ADV 98.79 89 999999999 86.58 105.45 percent of total billed charges METHADONE 3018035801_1 CDM 301 RC 80358 HCPCS outpatient 111 83.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 98.79 89 999999999 86.58 105.45 percent of total billed charges METHADONE 3018035801_1 CDM 301 RC 80358 HCPCS outpatient 111 83.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 98.79 89 999999999 86.58 105.45 percent of total billed charges METHADONE 3018035801_1 CDM 301 RC 80358 HCPCS outpatient 111 83.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 99.9 90 999999999 86.58 105.45 percent of total billed charges METHADONE 3018035801_1 CDM 301 RC 80358 HCPCS outpatient 111 83.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 105.45 95 999999999 86.58 105.45 percent of total billed charges METHADONE 3018035801_1 CDM 301 RC 80358 HCPCS outpatient 111 83.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 105.45 95 999999999 86.58 105.45 percent of total billed charges METHADONE 3018035801_1 CDM 301 RC 80358 HCPCS outpatient 111 83.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 98.79 89 999999999 86.58 105.45 percent of total billed charges METHADONE 3018035801_1 CDM 301 RC 80358 HCPCS outpatient 111 83.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 97.68 88 999999999 86.58 105.45 percent of total billed charges METHADONE 3018035801_1 CDM 301 RC 80358 HCPCS outpatient 111 83.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 98.79 89 999999999 86.58 105.45 percent of total billed charges "METHYLENEDIOXYAMPHETAMINES (MDA, MDEA, MDMA)" 3018035901_1 CDM 301 RC 80359 HCPCS outpatient 120 90 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 108 90 999999999 93.6 114 percent of total billed charges "METHYLENEDIOXYAMPHETAMINES (MDA, MDEA, MDMA)" 3018035901_1 CDM 301 RC 80359 HCPCS outpatient 120 90 AETNA MCR ADV AETNA MCR ADV 93.6 78 999999999 93.6 114 percent of total billed charges "METHYLENEDIOXYAMPHETAMINES (MDA, MDEA, MDMA)" 3018035901_1 CDM 301 RC 80359 HCPCS outpatient 120 90 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 105.08 87.57 999999999 93.6 114 percent of total billed charges "METHYLENEDIOXYAMPHETAMINES (MDA, MDEA, MDMA)" 3018035901_1 CDM 301 RC 80359 HCPCS outpatient 120 90 COORDINATED CARE MCAID COORDINATED CARE MCAID 102.08 85.07 999999999 93.6 114 percent of total billed charges "METHYLENEDIOXYAMPHETAMINES (MDA, MDEA, MDMA)" 3018035901_1 CDM 301 RC 80359 HCPCS outpatient 120 90 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 102.08 85.07 999999999 93.6 114 percent of total billed charges "METHYLENEDIOXYAMPHETAMINES (MDA, MDEA, MDMA)" 3018035901_1 CDM 301 RC 80359 HCPCS outpatient 120 90 MOLINA MCAID MOLINA MCAID 100.08 83.4 999999999 93.6 114 percent of total billed charges "METHYLENEDIOXYAMPHETAMINES (MDA, MDEA, MDMA)" 3018035901_1 CDM 301 RC 80359 HCPCS outpatient 120 90 MOLINA MCR ADV MOLINA MCR ADV 106.8 89 999999999 93.6 114 percent of total billed charges "METHYLENEDIOXYAMPHETAMINES (MDA, MDEA, MDMA)" 3018035901_1 CDM 301 RC 80359 HCPCS outpatient 120 90 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 106.8 89 999999999 93.6 114 percent of total billed charges "METHYLENEDIOXYAMPHETAMINES (MDA, MDEA, MDMA)" 3018035901_1 CDM 301 RC 80359 HCPCS outpatient 120 90 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 106.8 89 999999999 93.6 114 percent of total billed charges "METHYLENEDIOXYAMPHETAMINES (MDA, MDEA, MDMA)" 3018035901_1 CDM 301 RC 80359 HCPCS outpatient 120 90 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 108 90 999999999 93.6 114 percent of total billed charges "METHYLENEDIOXYAMPHETAMINES (MDA, MDEA, MDMA)" 3018035901_1 CDM 301 RC 80359 HCPCS outpatient 120 90 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 114 95 999999999 93.6 114 percent of total billed charges "METHYLENEDIOXYAMPHETAMINES (MDA, MDEA, MDMA)" 3018035901_1 CDM 301 RC 80359 HCPCS outpatient 120 90 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 114 95 999999999 93.6 114 percent of total billed charges "METHYLENEDIOXYAMPHETAMINES (MDA, MDEA, MDMA)" 3018035901_1 CDM 301 RC 80359 HCPCS outpatient 120 90 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 106.8 89 999999999 93.6 114 percent of total billed charges "METHYLENEDIOXYAMPHETAMINES (MDA, MDEA, MDMA)" 3018035901_1 CDM 301 RC 80359 HCPCS outpatient 120 90 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 105.6 88 999999999 93.6 114 percent of total billed charges "METHYLENEDIOXYAMPHETAMINES (MDA, MDEA, MDMA)" 3018035901_1 CDM 301 RC 80359 HCPCS outpatient 120 90 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 106.8 89 999999999 93.6 114 percent of total billed charges "OPIATES, 1 OR MORE" 3018036101_1 CDM 301 RC 80361 HCPCS outpatient 81 60.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 72.9 90 999999999 63.18 76.95 percent of total billed charges "OPIATES, 1 OR MORE" 3018036101_1 CDM 301 RC 80361 HCPCS outpatient 81 60.75 AETNA MCR ADV AETNA MCR ADV 63.18 78 999999999 63.18 76.95 percent of total billed charges "OPIATES, 1 OR MORE" 3018036101_1 CDM 301 RC 80361 HCPCS outpatient 81 60.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 70.93 87.57 999999999 63.18 76.95 percent of total billed charges "OPIATES, 1 OR MORE" 3018036101_1 CDM 301 RC 80361 HCPCS outpatient 81 60.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 68.91 85.07 999999999 63.18 76.95 percent of total billed charges "OPIATES, 1 OR MORE" 3018036101_1 CDM 301 RC 80361 HCPCS outpatient 81 60.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 68.91 85.07 999999999 63.18 76.95 percent of total billed charges "OPIATES, 1 OR MORE" 3018036101_1 CDM 301 RC 80361 HCPCS outpatient 81 60.75 MOLINA MCAID MOLINA MCAID 67.55 83.4 999999999 63.18 76.95 percent of total billed charges "OPIATES, 1 OR MORE" 3018036101_1 CDM 301 RC 80361 HCPCS outpatient 81 60.75 MOLINA MCR ADV MOLINA MCR ADV 72.09 89 999999999 63.18 76.95 percent of total billed charges "OPIATES, 1 OR MORE" 3018036101_1 CDM 301 RC 80361 HCPCS outpatient 81 60.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 72.09 89 999999999 63.18 76.95 percent of total billed charges "OPIATES, 1 OR MORE" 3018036101_1 CDM 301 RC 80361 HCPCS outpatient 81 60.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 72.09 89 999999999 63.18 76.95 percent of total billed charges "OPIATES, 1 OR MORE" 3018036101_1 CDM 301 RC 80361 HCPCS outpatient 81 60.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 72.9 90 999999999 63.18 76.95 percent of total billed charges "OPIATES, 1 OR MORE" 3018036101_1 CDM 301 RC 80361 HCPCS outpatient 81 60.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 76.95 95 999999999 63.18 76.95 percent of total billed charges "OPIATES, 1 OR MORE" 3018036101_1 CDM 301 RC 80361 HCPCS outpatient 81 60.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 76.95 95 999999999 63.18 76.95 percent of total billed charges "OPIATES, 1 OR MORE" 3018036101_1 CDM 301 RC 80361 HCPCS outpatient 81 60.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 72.09 89 999999999 63.18 76.95 percent of total billed charges "OPIATES, 1 OR MORE" 3018036101_1 CDM 301 RC 80361 HCPCS outpatient 81 60.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 71.28 88 999999999 63.18 76.95 percent of total billed charges "OPIATES, 1 OR MORE" 3018036101_1 CDM 301 RC 80361 HCPCS outpatient 81 60.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 72.09 89 999999999 63.18 76.95 percent of total billed charges OXYCODONE 3018036501_1 CDM 301 RC 80365 HCPCS outpatient 101 75.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 90.9 90 999999999 78.78 95.95 percent of total billed charges OXYCODONE 3018036501_1 CDM 301 RC 80365 HCPCS outpatient 101 75.75 AETNA MCR ADV AETNA MCR ADV 78.78 78 999999999 78.78 95.95 percent of total billed charges OXYCODONE 3018036501_1 CDM 301 RC 80365 HCPCS outpatient 101 75.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 88.45 87.57 999999999 78.78 95.95 percent of total billed charges OXYCODONE 3018036501_1 CDM 301 RC 80365 HCPCS outpatient 101 75.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 85.92 85.07 999999999 78.78 95.95 percent of total billed charges OXYCODONE 3018036501_1 CDM 301 RC 80365 HCPCS outpatient 101 75.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 85.92 85.07 999999999 78.78 95.95 percent of total billed charges OXYCODONE 3018036501_1 CDM 301 RC 80365 HCPCS outpatient 101 75.75 MOLINA MCAID MOLINA MCAID 84.23 83.4 999999999 78.78 95.95 percent of total billed charges OXYCODONE 3018036501_1 CDM 301 RC 80365 HCPCS outpatient 101 75.75 MOLINA MCR ADV MOLINA MCR ADV 89.89 89 999999999 78.78 95.95 percent of total billed charges OXYCODONE 3018036501_1 CDM 301 RC 80365 HCPCS outpatient 101 75.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 89.89 89 999999999 78.78 95.95 percent of total billed charges OXYCODONE 3018036501_1 CDM 301 RC 80365 HCPCS outpatient 101 75.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 89.89 89 999999999 78.78 95.95 percent of total billed charges OXYCODONE 3018036501_1 CDM 301 RC 80365 HCPCS outpatient 101 75.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 90.9 90 999999999 78.78 95.95 percent of total billed charges OXYCODONE 3018036501_1 CDM 301 RC 80365 HCPCS outpatient 101 75.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 95.95 95 999999999 78.78 95.95 percent of total billed charges OXYCODONE 3018036501_1 CDM 301 RC 80365 HCPCS outpatient 101 75.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 95.95 95 999999999 78.78 95.95 percent of total billed charges OXYCODONE 3018036501_1 CDM 301 RC 80365 HCPCS outpatient 101 75.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 89.89 89 999999999 78.78 95.95 percent of total billed charges OXYCODONE 3018036501_1 CDM 301 RC 80365 HCPCS outpatient 101 75.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 88.88 88 999999999 78.78 95.95 percent of total billed charges OXYCODONE 3018036501_1 CDM 301 RC 80365 HCPCS outpatient 101 75.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 89.89 89 999999999 78.78 95.95 percent of total billed charges TRAMADOL 3018037301_1 CDM 301 RC 80373 HCPCS outpatient 159 119.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 143.1 90 999999999 124.02 151.05 percent of total billed charges TRAMADOL 3018037301_1 CDM 301 RC 80373 HCPCS outpatient 159 119.25 AETNA MCR ADV AETNA MCR ADV 124.02 78 999999999 124.02 151.05 percent of total billed charges TRAMADOL 3018037301_1 CDM 301 RC 80373 HCPCS outpatient 159 119.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 139.24 87.57 999999999 124.02 151.05 percent of total billed charges TRAMADOL 3018037301_1 CDM 301 RC 80373 HCPCS outpatient 159 119.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 135.26 85.07 999999999 124.02 151.05 percent of total billed charges TRAMADOL 3018037301_1 CDM 301 RC 80373 HCPCS outpatient 159 119.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 135.26 85.07 999999999 124.02 151.05 percent of total billed charges TRAMADOL 3018037301_1 CDM 301 RC 80373 HCPCS outpatient 159 119.25 MOLINA MCAID MOLINA MCAID 132.61 83.4 999999999 124.02 151.05 percent of total billed charges TRAMADOL 3018037301_1 CDM 301 RC 80373 HCPCS outpatient 159 119.25 MOLINA MCR ADV MOLINA MCR ADV 141.51 89 999999999 124.02 151.05 percent of total billed charges TRAMADOL 3018037301_1 CDM 301 RC 80373 HCPCS outpatient 159 119.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 141.51 89 999999999 124.02 151.05 percent of total billed charges TRAMADOL 3018037301_1 CDM 301 RC 80373 HCPCS outpatient 159 119.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 141.51 89 999999999 124.02 151.05 percent of total billed charges TRAMADOL 3018037301_1 CDM 301 RC 80373 HCPCS outpatient 159 119.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 143.1 90 999999999 124.02 151.05 percent of total billed charges TRAMADOL 3018037301_1 CDM 301 RC 80373 HCPCS outpatient 159 119.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 151.05 95 999999999 124.02 151.05 percent of total billed charges TRAMADOL 3018037301_1 CDM 301 RC 80373 HCPCS outpatient 159 119.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 151.05 95 999999999 124.02 151.05 percent of total billed charges TRAMADOL 3018037301_1 CDM 301 RC 80373 HCPCS outpatient 159 119.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 141.51 89 999999999 124.02 151.05 percent of total billed charges TRAMADOL 3018037301_1 CDM 301 RC 80373 HCPCS outpatient 159 119.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 139.92 88 999999999 124.02 151.05 percent of total billed charges TRAMADOL 3018037301_1 CDM 301 RC 80373 HCPCS outpatient 159 119.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 141.51 89 999999999 124.02 151.05 percent of total billed charges ACTH STIMULATION PANEL; FOR ADRENAL INSUFFICIENCY THIS PANEL MUST INCLUDE THE FOLLOWING: CORTISOL (82533 X 2) 3018040001_1 CDM 301 RC 80400 HCPCS outpatient 375 281.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 337.5 90 999999999 292.5 356.25 percent of total billed charges ACTH STIMULATION PANEL; FOR ADRENAL INSUFFICIENCY THIS PANEL MUST INCLUDE THE FOLLOWING: CORTISOL (82533 X 2) 3018040001_1 CDM 301 RC 80400 HCPCS outpatient 375 281.25 AETNA MCR ADV AETNA MCR ADV 292.5 78 999999999 292.5 356.25 percent of total billed charges ACTH STIMULATION PANEL; FOR ADRENAL INSUFFICIENCY THIS PANEL MUST INCLUDE THE FOLLOWING: CORTISOL (82533 X 2) 3018040001_1 CDM 301 RC 80400 HCPCS outpatient 375 281.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 328.39 87.57 999999999 292.5 356.25 percent of total billed charges ACTH STIMULATION PANEL; FOR ADRENAL INSUFFICIENCY THIS PANEL MUST INCLUDE THE FOLLOWING: CORTISOL (82533 X 2) 3018040001_1 CDM 301 RC 80400 HCPCS outpatient 375 281.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 319.01 85.07 999999999 292.5 356.25 percent of total billed charges ACTH STIMULATION PANEL; FOR ADRENAL INSUFFICIENCY THIS PANEL MUST INCLUDE THE FOLLOWING: CORTISOL (82533 X 2) 3018040001_1 CDM 301 RC 80400 HCPCS outpatient 375 281.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 319.01 85.07 999999999 292.5 356.25 percent of total billed charges ACTH STIMULATION PANEL; FOR ADRENAL INSUFFICIENCY THIS PANEL MUST INCLUDE THE FOLLOWING: CORTISOL (82533 X 2) 3018040001_1 CDM 301 RC 80400 HCPCS outpatient 375 281.25 MOLINA MCAID MOLINA MCAID 312.75 83.4 999999999 292.5 356.25 percent of total billed charges ACTH STIMULATION PANEL; FOR ADRENAL INSUFFICIENCY THIS PANEL MUST INCLUDE THE FOLLOWING: CORTISOL (82533 X 2) 3018040001_1 CDM 301 RC 80400 HCPCS outpatient 375 281.25 MOLINA MCR ADV MOLINA MCR ADV 333.75 89 999999999 292.5 356.25 percent of total billed charges ACTH STIMULATION PANEL; FOR ADRENAL INSUFFICIENCY THIS PANEL MUST INCLUDE THE FOLLOWING: CORTISOL (82533 X 2) 3018040001_1 CDM 301 RC 80400 HCPCS outpatient 375 281.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 333.75 89 999999999 292.5 356.25 percent of total billed charges ACTH STIMULATION PANEL; FOR ADRENAL INSUFFICIENCY THIS PANEL MUST INCLUDE THE FOLLOWING: CORTISOL (82533 X 2) 3018040001_1 CDM 301 RC 80400 HCPCS outpatient 375 281.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 333.75 89 999999999 292.5 356.25 percent of total billed charges ACTH STIMULATION PANEL; FOR ADRENAL INSUFFICIENCY THIS PANEL MUST INCLUDE THE FOLLOWING: CORTISOL (82533 X 2) 3018040001_1 CDM 301 RC 80400 HCPCS outpatient 375 281.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 337.5 90 999999999 292.5 356.25 percent of total billed charges ACTH STIMULATION PANEL; FOR ADRENAL INSUFFICIENCY THIS PANEL MUST INCLUDE THE FOLLOWING: CORTISOL (82533 X 2) 3018040001_1 CDM 301 RC 80400 HCPCS outpatient 375 281.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 356.25 95 999999999 292.5 356.25 percent of total billed charges ACTH STIMULATION PANEL; FOR ADRENAL INSUFFICIENCY THIS PANEL MUST INCLUDE THE FOLLOWING: CORTISOL (82533 X 2) 3018040001_1 CDM 301 RC 80400 HCPCS outpatient 375 281.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 356.25 95 999999999 292.5 356.25 percent of total billed charges ACTH STIMULATION PANEL; FOR ADRENAL INSUFFICIENCY THIS PANEL MUST INCLUDE THE FOLLOWING: CORTISOL (82533 X 2) 3018040001_1 CDM 301 RC 80400 HCPCS outpatient 375 281.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 333.75 89 999999999 292.5 356.25 percent of total billed charges ACTH STIMULATION PANEL; FOR ADRENAL INSUFFICIENCY THIS PANEL MUST INCLUDE THE FOLLOWING: CORTISOL (82533 X 2) 3018040001_1 CDM 301 RC 80400 HCPCS outpatient 375 281.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 330 88 999999999 292.5 356.25 percent of total billed charges ACTH STIMULATION PANEL; FOR ADRENAL INSUFFICIENCY THIS PANEL MUST INCLUDE THE FOLLOWING: CORTISOL (82533 X 2) 3018040001_1 CDM 301 RC 80400 HCPCS outpatient 375 281.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 333.75 89 999999999 292.5 356.25 percent of total billed charges "KETONE BODY(S) (EG, ACETONE, ACETOACETIC ACID, BETA-HYDROXYBUTYRATE); QUANTITATIVE" 3018201001_1 CDM 301 RC 82010 HCPCS outpatient 94 70.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 84.6 90 999999999 73.32 89.3 percent of total billed charges "KETONE BODY(S) (EG, ACETONE, ACETOACETIC ACID, BETA-HYDROXYBUTYRATE); QUANTITATIVE" 3018201001_1 CDM 301 RC 82010 HCPCS outpatient 94 70.5 AETNA MCR ADV AETNA MCR ADV 73.32 78 999999999 73.32 89.3 percent of total billed charges "KETONE BODY(S) (EG, ACETONE, ACETOACETIC ACID, BETA-HYDROXYBUTYRATE); QUANTITATIVE" 3018201001_1 CDM 301 RC 82010 HCPCS outpatient 94 70.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 82.32 87.57 999999999 73.32 89.3 percent of total billed charges "KETONE BODY(S) (EG, ACETONE, ACETOACETIC ACID, BETA-HYDROXYBUTYRATE); QUANTITATIVE" 3018201001_1 CDM 301 RC 82010 HCPCS outpatient 94 70.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 79.97 85.07 999999999 73.32 89.3 percent of total billed charges "KETONE BODY(S) (EG, ACETONE, ACETOACETIC ACID, BETA-HYDROXYBUTYRATE); QUANTITATIVE" 3018201001_1 CDM 301 RC 82010 HCPCS outpatient 94 70.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 79.97 85.07 999999999 73.32 89.3 percent of total billed charges "KETONE BODY(S) (EG, ACETONE, ACETOACETIC ACID, BETA-HYDROXYBUTYRATE); QUANTITATIVE" 3018201001_1 CDM 301 RC 82010 HCPCS outpatient 94 70.5 MOLINA MCAID MOLINA MCAID 78.4 83.4 999999999 73.32 89.3 percent of total billed charges "KETONE BODY(S) (EG, ACETONE, ACETOACETIC ACID, BETA-HYDROXYBUTYRATE); QUANTITATIVE" 3018201001_1 CDM 301 RC 82010 HCPCS outpatient 94 70.5 MOLINA MCR ADV MOLINA MCR ADV 83.66 89 999999999 73.32 89.3 percent of total billed charges "KETONE BODY(S) (EG, ACETONE, ACETOACETIC ACID, BETA-HYDROXYBUTYRATE); QUANTITATIVE" 3018201001_1 CDM 301 RC 82010 HCPCS outpatient 94 70.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 83.66 89 999999999 73.32 89.3 percent of total billed charges "KETONE BODY(S) (EG, ACETONE, ACETOACETIC ACID, BETA-HYDROXYBUTYRATE); QUANTITATIVE" 3018201001_1 CDM 301 RC 82010 HCPCS outpatient 94 70.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 83.66 89 999999999 73.32 89.3 percent of total billed charges "KETONE BODY(S) (EG, ACETONE, ACETOACETIC ACID, BETA-HYDROXYBUTYRATE); QUANTITATIVE" 3018201001_1 CDM 301 RC 82010 HCPCS outpatient 94 70.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 84.6 90 999999999 73.32 89.3 percent of total billed charges "KETONE BODY(S) (EG, ACETONE, ACETOACETIC ACID, BETA-HYDROXYBUTYRATE); QUANTITATIVE" 3018201001_1 CDM 301 RC 82010 HCPCS outpatient 94 70.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 89.3 95 999999999 73.32 89.3 percent of total billed charges "KETONE BODY(S) (EG, ACETONE, ACETOACETIC ACID, BETA-HYDROXYBUTYRATE); QUANTITATIVE" 3018201001_1 CDM 301 RC 82010 HCPCS outpatient 94 70.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 89.3 95 999999999 73.32 89.3 percent of total billed charges "KETONE BODY(S) (EG, ACETONE, ACETOACETIC ACID, BETA-HYDROXYBUTYRATE); QUANTITATIVE" 3018201001_1 CDM 301 RC 82010 HCPCS outpatient 94 70.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 83.66 89 999999999 73.32 89.3 percent of total billed charges "KETONE BODY(S) (EG, ACETONE, ACETOACETIC ACID, BETA-HYDROXYBUTYRATE); QUANTITATIVE" 3018201001_1 CDM 301 RC 82010 HCPCS outpatient 94 70.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 82.72 88 999999999 73.32 89.3 percent of total billed charges "KETONE BODY(S) (EG, ACETONE, ACETOACETIC ACID, BETA-HYDROXYBUTYRATE); QUANTITATIVE" 3018201001_1 CDM 301 RC 82010 HCPCS outpatient 94 70.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 83.66 89 999999999 73.32 89.3 percent of total billed charges ADRENOCORTICOTROPIC HORMONE (ACTH) 3018202401_1 CDM 301 RC 82024 HCPCS outpatient 263 197.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 236.7 90 999999999 205.14 249.85 percent of total billed charges ADRENOCORTICOTROPIC HORMONE (ACTH) 3018202401_1 CDM 301 RC 82024 HCPCS outpatient 263 197.25 AETNA MCR ADV AETNA MCR ADV 205.14 78 999999999 205.14 249.85 percent of total billed charges ADRENOCORTICOTROPIC HORMONE (ACTH) 3018202401_1 CDM 301 RC 82024 HCPCS outpatient 263 197.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 230.31 87.57 999999999 205.14 249.85 percent of total billed charges ADRENOCORTICOTROPIC HORMONE (ACTH) 3018202401_1 CDM 301 RC 82024 HCPCS outpatient 263 197.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 223.73 85.07 999999999 205.14 249.85 percent of total billed charges ADRENOCORTICOTROPIC HORMONE (ACTH) 3018202401_1 CDM 301 RC 82024 HCPCS outpatient 263 197.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 223.73 85.07 999999999 205.14 249.85 percent of total billed charges ADRENOCORTICOTROPIC HORMONE (ACTH) 3018202401_1 CDM 301 RC 82024 HCPCS outpatient 263 197.25 MOLINA MCAID MOLINA MCAID 219.34 83.4 999999999 205.14 249.85 percent of total billed charges ADRENOCORTICOTROPIC HORMONE (ACTH) 3018202401_1 CDM 301 RC 82024 HCPCS outpatient 263 197.25 MOLINA MCR ADV MOLINA MCR ADV 234.07 89 999999999 205.14 249.85 percent of total billed charges ADRENOCORTICOTROPIC HORMONE (ACTH) 3018202401_1 CDM 301 RC 82024 HCPCS outpatient 263 197.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 234.07 89 999999999 205.14 249.85 percent of total billed charges ADRENOCORTICOTROPIC HORMONE (ACTH) 3018202401_1 CDM 301 RC 82024 HCPCS outpatient 263 197.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 234.07 89 999999999 205.14 249.85 percent of total billed charges ADRENOCORTICOTROPIC HORMONE (ACTH) 3018202401_1 CDM 301 RC 82024 HCPCS outpatient 263 197.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 236.7 90 999999999 205.14 249.85 percent of total billed charges ADRENOCORTICOTROPIC HORMONE (ACTH) 3018202401_1 CDM 301 RC 82024 HCPCS outpatient 263 197.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 249.85 95 999999999 205.14 249.85 percent of total billed charges ADRENOCORTICOTROPIC HORMONE (ACTH) 3018202401_1 CDM 301 RC 82024 HCPCS outpatient 263 197.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 249.85 95 999999999 205.14 249.85 percent of total billed charges ADRENOCORTICOTROPIC HORMONE (ACTH) 3018202401_1 CDM 301 RC 82024 HCPCS outpatient 263 197.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 234.07 89 999999999 205.14 249.85 percent of total billed charges ADRENOCORTICOTROPIC HORMONE (ACTH) 3018202401_1 CDM 301 RC 82024 HCPCS outpatient 263 197.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 231.44 88 999999999 205.14 249.85 percent of total billed charges ADRENOCORTICOTROPIC HORMONE (ACTH) 3018202401_1 CDM 301 RC 82024 HCPCS outpatient 263 197.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 234.07 89 999999999 205.14 249.85 percent of total billed charges "ALBUMIN; SERUM, PLASMA OR WHOLE BLOOD" 3018204001_1 CDM 301 RC 82040 HCPCS outpatient 63 47.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 56.7 90 999999999 49.14 59.85 percent of total billed charges "ALBUMIN; SERUM, PLASMA OR WHOLE BLOOD" 3018204001_1 CDM 301 RC 82040 HCPCS outpatient 63 47.25 AETNA MCR ADV AETNA MCR ADV 49.14 78 999999999 49.14 59.85 percent of total billed charges "ALBUMIN; SERUM, PLASMA OR WHOLE BLOOD" 3018204001_1 CDM 301 RC 82040 HCPCS outpatient 63 47.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 55.17 87.57 999999999 49.14 59.85 percent of total billed charges "ALBUMIN; SERUM, PLASMA OR WHOLE BLOOD" 3018204001_1 CDM 301 RC 82040 HCPCS outpatient 63 47.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 53.59 85.07 999999999 49.14 59.85 percent of total billed charges "ALBUMIN; SERUM, PLASMA OR WHOLE BLOOD" 3018204001_1 CDM 301 RC 82040 HCPCS outpatient 63 47.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 53.59 85.07 999999999 49.14 59.85 percent of total billed charges "ALBUMIN; SERUM, PLASMA OR WHOLE BLOOD" 3018204001_1 CDM 301 RC 82040 HCPCS outpatient 63 47.25 MOLINA MCAID MOLINA MCAID 52.54 83.4 999999999 49.14 59.85 percent of total billed charges "ALBUMIN; SERUM, PLASMA OR WHOLE BLOOD" 3018204001_1 CDM 301 RC 82040 HCPCS outpatient 63 47.25 MOLINA MCR ADV MOLINA MCR ADV 56.07 89 999999999 49.14 59.85 percent of total billed charges "ALBUMIN; SERUM, PLASMA OR WHOLE BLOOD" 3018204001_1 CDM 301 RC 82040 HCPCS outpatient 63 47.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 56.07 89 999999999 49.14 59.85 percent of total billed charges "ALBUMIN; SERUM, PLASMA OR WHOLE BLOOD" 3018204001_1 CDM 301 RC 82040 HCPCS outpatient 63 47.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 56.07 89 999999999 49.14 59.85 percent of total billed charges "ALBUMIN; SERUM, PLASMA OR WHOLE BLOOD" 3018204001_1 CDM 301 RC 82040 HCPCS outpatient 63 47.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 56.7 90 999999999 49.14 59.85 percent of total billed charges "ALBUMIN; SERUM, PLASMA OR WHOLE BLOOD" 3018204001_1 CDM 301 RC 82040 HCPCS outpatient 63 47.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 59.85 95 999999999 49.14 59.85 percent of total billed charges "ALBUMIN; SERUM, PLASMA OR WHOLE BLOOD" 3018204001_1 CDM 301 RC 82040 HCPCS outpatient 63 47.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 59.85 95 999999999 49.14 59.85 percent of total billed charges "ALBUMIN; SERUM, PLASMA OR WHOLE BLOOD" 3018204001_1 CDM 301 RC 82040 HCPCS outpatient 63 47.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 56.07 89 999999999 49.14 59.85 percent of total billed charges "ALBUMIN; SERUM, PLASMA OR WHOLE BLOOD" 3018204001_1 CDM 301 RC 82040 HCPCS outpatient 63 47.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 55.44 88 999999999 49.14 59.85 percent of total billed charges "ALBUMIN; SERUM, PLASMA OR WHOLE BLOOD" 3018204001_1 CDM 301 RC 82040 HCPCS outpatient 63 47.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 56.07 89 999999999 49.14 59.85 percent of total billed charges "ALBUMIN; URINE (EG, MICROALBUMIN), QUANTITATIVE" 3018204301_1 CDM 301 RC 82043 HCPCS outpatient 89 66.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 80.1 90 999999999 69.42 84.55 percent of total billed charges "ALBUMIN; URINE (EG, MICROALBUMIN), QUANTITATIVE" 3018204301_1 CDM 301 RC 82043 HCPCS outpatient 89 66.75 AETNA MCR ADV AETNA MCR ADV 69.42 78 999999999 69.42 84.55 percent of total billed charges "ALBUMIN; URINE (EG, MICROALBUMIN), QUANTITATIVE" 3018204301_1 CDM 301 RC 82043 HCPCS outpatient 89 66.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 77.94 87.57 999999999 69.42 84.55 percent of total billed charges "ALBUMIN; URINE (EG, MICROALBUMIN), QUANTITATIVE" 3018204301_1 CDM 301 RC 82043 HCPCS outpatient 89 66.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 75.71 85.07 999999999 69.42 84.55 percent of total billed charges "ALBUMIN; URINE (EG, MICROALBUMIN), QUANTITATIVE" 3018204301_1 CDM 301 RC 82043 HCPCS outpatient 89 66.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 75.71 85.07 999999999 69.42 84.55 percent of total billed charges "ALBUMIN; URINE (EG, MICROALBUMIN), QUANTITATIVE" 3018204301_1 CDM 301 RC 82043 HCPCS outpatient 89 66.75 MOLINA MCAID MOLINA MCAID 74.23 83.4 999999999 69.42 84.55 percent of total billed charges "ALBUMIN; URINE (EG, MICROALBUMIN), QUANTITATIVE" 3018204301_1 CDM 301 RC 82043 HCPCS outpatient 89 66.75 MOLINA MCR ADV MOLINA MCR ADV 79.21 89 999999999 69.42 84.55 percent of total billed charges "ALBUMIN; URINE (EG, MICROALBUMIN), QUANTITATIVE" 3018204301_1 CDM 301 RC 82043 HCPCS outpatient 89 66.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 79.21 89 999999999 69.42 84.55 percent of total billed charges "ALBUMIN; URINE (EG, MICROALBUMIN), QUANTITATIVE" 3018204301_1 CDM 301 RC 82043 HCPCS outpatient 89 66.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 79.21 89 999999999 69.42 84.55 percent of total billed charges "ALBUMIN; URINE (EG, MICROALBUMIN), QUANTITATIVE" 3018204301_1 CDM 301 RC 82043 HCPCS outpatient 89 66.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 80.1 90 999999999 69.42 84.55 percent of total billed charges "ALBUMIN; URINE (EG, MICROALBUMIN), QUANTITATIVE" 3018204301_1 CDM 301 RC 82043 HCPCS outpatient 89 66.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 84.55 95 999999999 69.42 84.55 percent of total billed charges "ALBUMIN; URINE (EG, MICROALBUMIN), QUANTITATIVE" 3018204301_1 CDM 301 RC 82043 HCPCS outpatient 89 66.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 84.55 95 999999999 69.42 84.55 percent of total billed charges "ALBUMIN; URINE (EG, MICROALBUMIN), QUANTITATIVE" 3018204301_1 CDM 301 RC 82043 HCPCS outpatient 89 66.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 79.21 89 999999999 69.42 84.55 percent of total billed charges "ALBUMIN; URINE (EG, MICROALBUMIN), QUANTITATIVE" 3018204301_1 CDM 301 RC 82043 HCPCS outpatient 89 66.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 78.32 88 999999999 69.42 84.55 percent of total billed charges "ALBUMIN; URINE (EG, MICROALBUMIN), QUANTITATIVE" 3018204301_1 CDM 301 RC 82043 HCPCS outpatient 89 66.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 79.21 89 999999999 69.42 84.55 percent of total billed charges ALPHA-FETOPROTEIN (AFP); SERUM 3018210501_1 CDM 301 RC 82105 HCPCS outpatient 112 84 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 100.8 90 999999999 87.36 106.4 percent of total billed charges ALPHA-FETOPROTEIN (AFP); SERUM 3018210501_1 CDM 301 RC 82105 HCPCS outpatient 112 84 AETNA MCR ADV AETNA MCR ADV 87.36 78 999999999 87.36 106.4 percent of total billed charges ALPHA-FETOPROTEIN (AFP); SERUM 3018210501_1 CDM 301 RC 82105 HCPCS outpatient 112 84 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 98.08 87.57 999999999 87.36 106.4 percent of total billed charges ALPHA-FETOPROTEIN (AFP); SERUM 3018210501_1 CDM 301 RC 82105 HCPCS outpatient 112 84 COORDINATED CARE MCAID COORDINATED CARE MCAID 95.28 85.07 999999999 87.36 106.4 percent of total billed charges ALPHA-FETOPROTEIN (AFP); SERUM 3018210501_1 CDM 301 RC 82105 HCPCS outpatient 112 84 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 95.28 85.07 999999999 87.36 106.4 percent of total billed charges ALPHA-FETOPROTEIN (AFP); SERUM 3018210501_1 CDM 301 RC 82105 HCPCS outpatient 112 84 MOLINA MCAID MOLINA MCAID 93.41 83.4 999999999 87.36 106.4 percent of total billed charges ALPHA-FETOPROTEIN (AFP); SERUM 3018210501_1 CDM 301 RC 82105 HCPCS outpatient 112 84 MOLINA MCR ADV MOLINA MCR ADV 99.68 89 999999999 87.36 106.4 percent of total billed charges ALPHA-FETOPROTEIN (AFP); SERUM 3018210501_1 CDM 301 RC 82105 HCPCS outpatient 112 84 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 99.68 89 999999999 87.36 106.4 percent of total billed charges ALPHA-FETOPROTEIN (AFP); SERUM 3018210501_1 CDM 301 RC 82105 HCPCS outpatient 112 84 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 99.68 89 999999999 87.36 106.4 percent of total billed charges ALPHA-FETOPROTEIN (AFP); SERUM 3018210501_1 CDM 301 RC 82105 HCPCS outpatient 112 84 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 100.8 90 999999999 87.36 106.4 percent of total billed charges ALPHA-FETOPROTEIN (AFP); SERUM 3018210501_1 CDM 301 RC 82105 HCPCS outpatient 112 84 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 106.4 95 999999999 87.36 106.4 percent of total billed charges ALPHA-FETOPROTEIN (AFP); SERUM 3018210501_1 CDM 301 RC 82105 HCPCS outpatient 112 84 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 106.4 95 999999999 87.36 106.4 percent of total billed charges ALPHA-FETOPROTEIN (AFP); SERUM 3018210501_1 CDM 301 RC 82105 HCPCS outpatient 112 84 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 99.68 89 999999999 87.36 106.4 percent of total billed charges ALPHA-FETOPROTEIN (AFP); SERUM 3018210501_1 CDM 301 RC 82105 HCPCS outpatient 112 84 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 98.56 88 999999999 87.36 106.4 percent of total billed charges ALPHA-FETOPROTEIN (AFP); SERUM 3018210501_1 CDM 301 RC 82105 HCPCS outpatient 112 84 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 99.68 89 999999999 87.36 106.4 percent of total billed charges AMMONIA 3018214001_1 CDM 301 RC 82140 HCPCS outpatient 157 117.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 141.3 90 999999999 122.46 149.15 percent of total billed charges AMMONIA 3018214001_1 CDM 301 RC 82140 HCPCS outpatient 157 117.75 AETNA MCR ADV AETNA MCR ADV 122.46 78 999999999 122.46 149.15 percent of total billed charges AMMONIA 3018214001_1 CDM 301 RC 82140 HCPCS outpatient 157 117.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 137.48 87.57 999999999 122.46 149.15 percent of total billed charges AMMONIA 3018214001_1 CDM 301 RC 82140 HCPCS outpatient 157 117.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 133.56 85.07 999999999 122.46 149.15 percent of total billed charges AMMONIA 3018214001_1 CDM 301 RC 82140 HCPCS outpatient 157 117.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 133.56 85.07 999999999 122.46 149.15 percent of total billed charges AMMONIA 3018214001_1 CDM 301 RC 82140 HCPCS outpatient 157 117.75 MOLINA MCAID MOLINA MCAID 130.94 83.4 999999999 122.46 149.15 percent of total billed charges AMMONIA 3018214001_1 CDM 301 RC 82140 HCPCS outpatient 157 117.75 MOLINA MCR ADV MOLINA MCR ADV 139.73 89 999999999 122.46 149.15 percent of total billed charges AMMONIA 3018214001_1 CDM 301 RC 82140 HCPCS outpatient 157 117.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 139.73 89 999999999 122.46 149.15 percent of total billed charges AMMONIA 3018214001_1 CDM 301 RC 82140 HCPCS outpatient 157 117.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 139.73 89 999999999 122.46 149.15 percent of total billed charges AMMONIA 3018214001_1 CDM 301 RC 82140 HCPCS outpatient 157 117.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 141.3 90 999999999 122.46 149.15 percent of total billed charges AMMONIA 3018214001_1 CDM 301 RC 82140 HCPCS outpatient 157 117.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 149.15 95 999999999 122.46 149.15 percent of total billed charges AMMONIA 3018214001_1 CDM 301 RC 82140 HCPCS outpatient 157 117.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 149.15 95 999999999 122.46 149.15 percent of total billed charges AMMONIA 3018214001_1 CDM 301 RC 82140 HCPCS outpatient 157 117.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 139.73 89 999999999 122.46 149.15 percent of total billed charges AMMONIA 3018214001_1 CDM 301 RC 82140 HCPCS outpatient 157 117.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 138.16 88 999999999 122.46 149.15 percent of total billed charges AMMONIA 3018214001_1 CDM 301 RC 82140 HCPCS outpatient 157 117.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 139.73 89 999999999 122.46 149.15 percent of total billed charges AMYLASE 3018215001_1 CDM 301 RC 82150 HCPCS outpatient 100 75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 90 90 999999999 78 95 percent of total billed charges AMYLASE 3018215001_1 CDM 301 RC 82150 HCPCS outpatient 100 75 AETNA MCR ADV AETNA MCR ADV 78 78 999999999 78 95 percent of total billed charges AMYLASE 3018215001_1 CDM 301 RC 82150 HCPCS outpatient 100 75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 87.57 87.57 999999999 78 95 percent of total billed charges AMYLASE 3018215001_1 CDM 301 RC 82150 HCPCS outpatient 100 75 COORDINATED CARE MCAID COORDINATED CARE MCAID 85.07 85.07 999999999 78 95 percent of total billed charges AMYLASE 3018215001_1 CDM 301 RC 82150 HCPCS outpatient 100 75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 85.07 85.07 999999999 78 95 percent of total billed charges AMYLASE 3018215001_1 CDM 301 RC 82150 HCPCS outpatient 100 75 MOLINA MCAID MOLINA MCAID 83.4 83.4 999999999 78 95 percent of total billed charges AMYLASE 3018215001_1 CDM 301 RC 82150 HCPCS outpatient 100 75 MOLINA MCR ADV MOLINA MCR ADV 89 89 999999999 78 95 percent of total billed charges AMYLASE 3018215001_1 CDM 301 RC 82150 HCPCS outpatient 100 75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 89 89 999999999 78 95 percent of total billed charges AMYLASE 3018215001_1 CDM 301 RC 82150 HCPCS outpatient 100 75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 89 89 999999999 78 95 percent of total billed charges AMYLASE 3018215001_1 CDM 301 RC 82150 HCPCS outpatient 100 75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 90 90 999999999 78 95 percent of total billed charges AMYLASE 3018215001_1 CDM 301 RC 82150 HCPCS outpatient 100 75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 95 95 999999999 78 95 percent of total billed charges AMYLASE 3018215001_1 CDM 301 RC 82150 HCPCS outpatient 100 75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 95 95 999999999 78 95 percent of total billed charges AMYLASE 3018215001_1 CDM 301 RC 82150 HCPCS outpatient 100 75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 89 89 999999999 78 95 percent of total billed charges AMYLASE 3018215001_1 CDM 301 RC 82150 HCPCS outpatient 100 75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 88 88 999999999 78 95 percent of total billed charges AMYLASE 3018215001_1 CDM 301 RC 82150 HCPCS outpatient 100 75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 89 89 999999999 78 95 percent of total billed charges BETA-2 MICROGLOBULIN 3018223201_1 CDM 301 RC 82232 HCPCS outpatient 132 99 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 118.8 90 999999999 102.96 125.4 percent of total billed charges BETA-2 MICROGLOBULIN 3018223201_1 CDM 301 RC 82232 HCPCS outpatient 132 99 AETNA MCR ADV AETNA MCR ADV 102.96 78 999999999 102.96 125.4 percent of total billed charges BETA-2 MICROGLOBULIN 3018223201_1 CDM 301 RC 82232 HCPCS outpatient 132 99 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 115.59 87.57 999999999 102.96 125.4 percent of total billed charges BETA-2 MICROGLOBULIN 3018223201_1 CDM 301 RC 82232 HCPCS outpatient 132 99 COORDINATED CARE MCAID COORDINATED CARE MCAID 112.29 85.07 999999999 102.96 125.4 percent of total billed charges BETA-2 MICROGLOBULIN 3018223201_1 CDM 301 RC 82232 HCPCS outpatient 132 99 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 112.29 85.07 999999999 102.96 125.4 percent of total billed charges BETA-2 MICROGLOBULIN 3018223201_1 CDM 301 RC 82232 HCPCS outpatient 132 99 MOLINA MCAID MOLINA MCAID 110.09 83.4 999999999 102.96 125.4 percent of total billed charges BETA-2 MICROGLOBULIN 3018223201_1 CDM 301 RC 82232 HCPCS outpatient 132 99 MOLINA MCR ADV MOLINA MCR ADV 117.48 89 999999999 102.96 125.4 percent of total billed charges BETA-2 MICROGLOBULIN 3018223201_1 CDM 301 RC 82232 HCPCS outpatient 132 99 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 117.48 89 999999999 102.96 125.4 percent of total billed charges BETA-2 MICROGLOBULIN 3018223201_1 CDM 301 RC 82232 HCPCS outpatient 132 99 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 117.48 89 999999999 102.96 125.4 percent of total billed charges BETA-2 MICROGLOBULIN 3018223201_1 CDM 301 RC 82232 HCPCS outpatient 132 99 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 118.8 90 999999999 102.96 125.4 percent of total billed charges BETA-2 MICROGLOBULIN 3018223201_1 CDM 301 RC 82232 HCPCS outpatient 132 99 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 125.4 95 999999999 102.96 125.4 percent of total billed charges BETA-2 MICROGLOBULIN 3018223201_1 CDM 301 RC 82232 HCPCS outpatient 132 99 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 125.4 95 999999999 102.96 125.4 percent of total billed charges BETA-2 MICROGLOBULIN 3018223201_1 CDM 301 RC 82232 HCPCS outpatient 132 99 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 117.48 89 999999999 102.96 125.4 percent of total billed charges BETA-2 MICROGLOBULIN 3018223201_1 CDM 301 RC 82232 HCPCS outpatient 132 99 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 116.16 88 999999999 102.96 125.4 percent of total billed charges BETA-2 MICROGLOBULIN 3018223201_1 CDM 301 RC 82232 HCPCS outpatient 132 99 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 117.48 89 999999999 102.96 125.4 percent of total billed charges BILIRUBIN; TOTAL 3018224701_1 CDM 301 RC 82247 HCPCS outpatient 80 60 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 72 90 999999999 62.4 76 percent of total billed charges BILIRUBIN; TOTAL 3018224701_1 CDM 301 RC 82247 HCPCS outpatient 80 60 AETNA MCR ADV AETNA MCR ADV 62.4 78 999999999 62.4 76 percent of total billed charges BILIRUBIN; TOTAL 3018224701_1 CDM 301 RC 82247 HCPCS outpatient 80 60 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 70.06 87.57 999999999 62.4 76 percent of total billed charges BILIRUBIN; TOTAL 3018224701_1 CDM 301 RC 82247 HCPCS outpatient 80 60 COORDINATED CARE MCAID COORDINATED CARE MCAID 68.06 85.07 999999999 62.4 76 percent of total billed charges BILIRUBIN; TOTAL 3018224701_1 CDM 301 RC 82247 HCPCS outpatient 80 60 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 68.06 85.07 999999999 62.4 76 percent of total billed charges BILIRUBIN; TOTAL 3018224701_1 CDM 301 RC 82247 HCPCS outpatient 80 60 MOLINA MCAID MOLINA MCAID 66.72 83.4 999999999 62.4 76 percent of total billed charges BILIRUBIN; TOTAL 3018224701_1 CDM 301 RC 82247 HCPCS outpatient 80 60 MOLINA MCR ADV MOLINA MCR ADV 71.2 89 999999999 62.4 76 percent of total billed charges BILIRUBIN; TOTAL 3018224701_1 CDM 301 RC 82247 HCPCS outpatient 80 60 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 71.2 89 999999999 62.4 76 percent of total billed charges BILIRUBIN; TOTAL 3018224701_1 CDM 301 RC 82247 HCPCS outpatient 80 60 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 71.2 89 999999999 62.4 76 percent of total billed charges BILIRUBIN; TOTAL 3018224701_1 CDM 301 RC 82247 HCPCS outpatient 80 60 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 72 90 999999999 62.4 76 percent of total billed charges BILIRUBIN; TOTAL 3018224701_1 CDM 301 RC 82247 HCPCS outpatient 80 60 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 76 95 999999999 62.4 76 percent of total billed charges BILIRUBIN; TOTAL 3018224701_1 CDM 301 RC 82247 HCPCS outpatient 80 60 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 76 95 999999999 62.4 76 percent of total billed charges BILIRUBIN; TOTAL 3018224701_1 CDM 301 RC 82247 HCPCS outpatient 80 60 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 71.2 89 999999999 62.4 76 percent of total billed charges BILIRUBIN; TOTAL 3018224701_1 CDM 301 RC 82247 HCPCS outpatient 80 60 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 70.4 88 999999999 62.4 76 percent of total billed charges BILIRUBIN; TOTAL 3018224701_1 CDM 301 RC 82247 HCPCS outpatient 80 60 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 71.2 89 999999999 62.4 76 percent of total billed charges BILIRUBIN; DIRECT 3018224801_1 CDM 301 RC 82248 HCPCS outpatient 65 48.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 58.5 90 999999999 50.7 61.75 percent of total billed charges BILIRUBIN; DIRECT 3018224801_1 CDM 301 RC 82248 HCPCS outpatient 65 48.75 AETNA MCR ADV AETNA MCR ADV 50.7 78 999999999 50.7 61.75 percent of total billed charges BILIRUBIN; DIRECT 3018224801_1 CDM 301 RC 82248 HCPCS outpatient 65 48.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 56.92 87.57 999999999 50.7 61.75 percent of total billed charges BILIRUBIN; DIRECT 3018224801_1 CDM 301 RC 82248 HCPCS outpatient 65 48.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 55.3 85.07 999999999 50.7 61.75 percent of total billed charges BILIRUBIN; DIRECT 3018224801_1 CDM 301 RC 82248 HCPCS outpatient 65 48.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 55.3 85.07 999999999 50.7 61.75 percent of total billed charges BILIRUBIN; DIRECT 3018224801_1 CDM 301 RC 82248 HCPCS outpatient 65 48.75 MOLINA MCAID MOLINA MCAID 54.21 83.4 999999999 50.7 61.75 percent of total billed charges BILIRUBIN; DIRECT 3018224801_1 CDM 301 RC 82248 HCPCS outpatient 65 48.75 MOLINA MCR ADV MOLINA MCR ADV 57.85 89 999999999 50.7 61.75 percent of total billed charges BILIRUBIN; DIRECT 3018224801_1 CDM 301 RC 82248 HCPCS outpatient 65 48.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 57.85 89 999999999 50.7 61.75 percent of total billed charges BILIRUBIN; DIRECT 3018224801_1 CDM 301 RC 82248 HCPCS outpatient 65 48.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 57.85 89 999999999 50.7 61.75 percent of total billed charges BILIRUBIN; DIRECT 3018224801_1 CDM 301 RC 82248 HCPCS outpatient 65 48.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 58.5 90 999999999 50.7 61.75 percent of total billed charges BILIRUBIN; DIRECT 3018224801_1 CDM 301 RC 82248 HCPCS outpatient 65 48.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 61.75 95 999999999 50.7 61.75 percent of total billed charges BILIRUBIN; DIRECT 3018224801_1 CDM 301 RC 82248 HCPCS outpatient 65 48.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 61.75 95 999999999 50.7 61.75 percent of total billed charges BILIRUBIN; DIRECT 3018224801_1 CDM 301 RC 82248 HCPCS outpatient 65 48.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 57.85 89 999999999 50.7 61.75 percent of total billed charges BILIRUBIN; DIRECT 3018224801_1 CDM 301 RC 82248 HCPCS outpatient 65 48.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 57.2 88 999999999 50.7 61.75 percent of total billed charges BILIRUBIN; DIRECT 3018224801_1 CDM 301 RC 82248 HCPCS outpatient 65 48.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 57.85 89 999999999 50.7 61.75 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 3018227001_1 CDM 301 RC 82270 HCPCS outpatient 44 33 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 39.6 90 999999999 34.32 41.8 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 3018227001_1 CDM 301 RC 82270 HCPCS outpatient 44 33 AETNA MCR ADV AETNA MCR ADV 34.32 78 999999999 34.32 41.8 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 3018227001_1 CDM 301 RC 82270 HCPCS outpatient 44 33 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 38.53 87.57 999999999 34.32 41.8 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 3018227001_1 CDM 301 RC 82270 HCPCS outpatient 44 33 COORDINATED CARE MCAID COORDINATED CARE MCAID 37.43 85.07 999999999 34.32 41.8 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 3018227001_1 CDM 301 RC 82270 HCPCS outpatient 44 33 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 37.43 85.07 999999999 34.32 41.8 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 3018227001_1 CDM 301 RC 82270 HCPCS outpatient 44 33 MOLINA MCAID MOLINA MCAID 36.7 83.4 999999999 34.32 41.8 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 3018227001_1 CDM 301 RC 82270 HCPCS outpatient 44 33 MOLINA MCR ADV MOLINA MCR ADV 39.16 89 999999999 34.32 41.8 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 3018227001_1 CDM 301 RC 82270 HCPCS outpatient 44 33 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 39.16 89 999999999 34.32 41.8 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 3018227001_1 CDM 301 RC 82270 HCPCS outpatient 44 33 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 39.16 89 999999999 34.32 41.8 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 3018227001_1 CDM 301 RC 82270 HCPCS outpatient 44 33 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 39.6 90 999999999 34.32 41.8 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 3018227001_1 CDM 301 RC 82270 HCPCS outpatient 44 33 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 41.8 95 999999999 34.32 41.8 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 3018227001_1 CDM 301 RC 82270 HCPCS outpatient 44 33 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 41.8 95 999999999 34.32 41.8 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 3018227001_1 CDM 301 RC 82270 HCPCS outpatient 44 33 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 39.16 89 999999999 34.32 41.8 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 3018227001_1 CDM 301 RC 82270 HCPCS outpatient 44 33 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 38.72 88 999999999 34.32 41.8 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 3018227001_1 CDM 301 RC 82270 HCPCS outpatient 44 33 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 39.16 89 999999999 34.32 41.8 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 3018227401_1 CDM 301 RC 82274 HCPCS outpatient 50 37.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 45 90 999999999 39 47.5 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 3018227401_1 CDM 301 RC 82274 HCPCS outpatient 50 37.5 AETNA MCR ADV AETNA MCR ADV 39 78 999999999 39 47.5 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 3018227401_1 CDM 301 RC 82274 HCPCS outpatient 50 37.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 43.79 87.57 999999999 39 47.5 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 3018227401_1 CDM 301 RC 82274 HCPCS outpatient 50 37.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 42.54 85.07 999999999 39 47.5 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 3018227401_1 CDM 301 RC 82274 HCPCS outpatient 50 37.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 42.54 85.07 999999999 39 47.5 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 3018227401_1 CDM 301 RC 82274 HCPCS outpatient 50 37.5 MOLINA MCAID MOLINA MCAID 41.7 83.4 999999999 39 47.5 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 3018227401_1 CDM 301 RC 82274 HCPCS outpatient 50 37.5 MOLINA MCR ADV MOLINA MCR ADV 44.5 89 999999999 39 47.5 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 3018227401_1 CDM 301 RC 82274 HCPCS outpatient 50 37.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 44.5 89 999999999 39 47.5 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 3018227401_1 CDM 301 RC 82274 HCPCS outpatient 50 37.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 44.5 89 999999999 39 47.5 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 3018227401_1 CDM 301 RC 82274 HCPCS outpatient 50 37.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 45 90 999999999 39 47.5 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 3018227401_1 CDM 301 RC 82274 HCPCS outpatient 50 37.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 47.5 95 999999999 39 47.5 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 3018227401_1 CDM 301 RC 82274 HCPCS outpatient 50 37.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 47.5 95 999999999 39 47.5 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 3018227401_1 CDM 301 RC 82274 HCPCS outpatient 50 37.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 44.5 89 999999999 39 47.5 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 3018227401_1 CDM 301 RC 82274 HCPCS outpatient 50 37.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 44 88 999999999 39 47.5 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 3018227401_1 CDM 301 RC 82274 HCPCS outpatient 50 37.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 44.5 89 999999999 39 47.5 percent of total billed charges "VITAMIN D; 25 HYDROXY, INCLUDES FRACTION(S), IF PERFORMED" 3018230601_1 CDM 301 RC 82306 HCPCS outpatient 130 97.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 117 90 999999999 101.4 123.5 percent of total billed charges "VITAMIN D; 25 HYDROXY, INCLUDES FRACTION(S), IF PERFORMED" 3018230601_1 CDM 301 RC 82306 HCPCS outpatient 130 97.5 AETNA MCR ADV AETNA MCR ADV 101.4 78 999999999 101.4 123.5 percent of total billed charges "VITAMIN D; 25 HYDROXY, INCLUDES FRACTION(S), IF PERFORMED" 3018230601_1 CDM 301 RC 82306 HCPCS outpatient 130 97.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 113.84 87.57 999999999 101.4 123.5 percent of total billed charges "VITAMIN D; 25 HYDROXY, INCLUDES FRACTION(S), IF PERFORMED" 3018230601_1 CDM 301 RC 82306 HCPCS outpatient 130 97.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 110.59 85.07 999999999 101.4 123.5 percent of total billed charges "VITAMIN D; 25 HYDROXY, INCLUDES FRACTION(S), IF PERFORMED" 3018230601_1 CDM 301 RC 82306 HCPCS outpatient 130 97.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 110.59 85.07 999999999 101.4 123.5 percent of total billed charges "VITAMIN D; 25 HYDROXY, INCLUDES FRACTION(S), IF PERFORMED" 3018230601_1 CDM 301 RC 82306 HCPCS outpatient 130 97.5 MOLINA MCAID MOLINA MCAID 108.42 83.4 999999999 101.4 123.5 percent of total billed charges "VITAMIN D; 25 HYDROXY, INCLUDES FRACTION(S), IF PERFORMED" 3018230601_1 CDM 301 RC 82306 HCPCS outpatient 130 97.5 MOLINA MCR ADV MOLINA MCR ADV 115.7 89 999999999 101.4 123.5 percent of total billed charges "VITAMIN D; 25 HYDROXY, INCLUDES FRACTION(S), IF PERFORMED" 3018230601_1 CDM 301 RC 82306 HCPCS outpatient 130 97.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 115.7 89 999999999 101.4 123.5 percent of total billed charges "VITAMIN D; 25 HYDROXY, INCLUDES FRACTION(S), IF PERFORMED" 3018230601_1 CDM 301 RC 82306 HCPCS outpatient 130 97.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 115.7 89 999999999 101.4 123.5 percent of total billed charges "VITAMIN D; 25 HYDROXY, INCLUDES FRACTION(S), IF PERFORMED" 3018230601_1 CDM 301 RC 82306 HCPCS outpatient 130 97.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 117 90 999999999 101.4 123.5 percent of total billed charges "VITAMIN D; 25 HYDROXY, INCLUDES FRACTION(S), IF PERFORMED" 3018230601_1 CDM 301 RC 82306 HCPCS outpatient 130 97.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 123.5 95 999999999 101.4 123.5 percent of total billed charges "VITAMIN D; 25 HYDROXY, INCLUDES FRACTION(S), IF PERFORMED" 3018230601_1 CDM 301 RC 82306 HCPCS outpatient 130 97.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 123.5 95 999999999 101.4 123.5 percent of total billed charges "VITAMIN D; 25 HYDROXY, INCLUDES FRACTION(S), IF PERFORMED" 3018230601_1 CDM 301 RC 82306 HCPCS outpatient 130 97.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 115.7 89 999999999 101.4 123.5 percent of total billed charges "VITAMIN D; 25 HYDROXY, INCLUDES FRACTION(S), IF PERFORMED" 3018230601_1 CDM 301 RC 82306 HCPCS outpatient 130 97.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 114.4 88 999999999 101.4 123.5 percent of total billed charges "VITAMIN D; 25 HYDROXY, INCLUDES FRACTION(S), IF PERFORMED" 3018230601_1 CDM 301 RC 82306 HCPCS outpatient 130 97.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 115.7 89 999999999 101.4 123.5 percent of total billed charges CALCIUM; TOTAL 3018231001_1 CDM 301 RC 82310 HCPCS outpatient 56 42 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50.4 90 999999999 43.68 53.2 percent of total billed charges CALCIUM; TOTAL 3018231001_1 CDM 301 RC 82310 HCPCS outpatient 56 42 AETNA MCR ADV AETNA MCR ADV 43.68 78 999999999 43.68 53.2 percent of total billed charges CALCIUM; TOTAL 3018231001_1 CDM 301 RC 82310 HCPCS outpatient 56 42 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 49.04 87.57 999999999 43.68 53.2 percent of total billed charges CALCIUM; TOTAL 3018231001_1 CDM 301 RC 82310 HCPCS outpatient 56 42 COORDINATED CARE MCAID COORDINATED CARE MCAID 47.64 85.07 999999999 43.68 53.2 percent of total billed charges CALCIUM; TOTAL 3018231001_1 CDM 301 RC 82310 HCPCS outpatient 56 42 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 47.64 85.07 999999999 43.68 53.2 percent of total billed charges CALCIUM; TOTAL 3018231001_1 CDM 301 RC 82310 HCPCS outpatient 56 42 MOLINA MCAID MOLINA MCAID 46.7 83.4 999999999 43.68 53.2 percent of total billed charges CALCIUM; TOTAL 3018231001_1 CDM 301 RC 82310 HCPCS outpatient 56 42 MOLINA MCR ADV MOLINA MCR ADV 49.84 89 999999999 43.68 53.2 percent of total billed charges CALCIUM; TOTAL 3018231001_1 CDM 301 RC 82310 HCPCS outpatient 56 42 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 49.84 89 999999999 43.68 53.2 percent of total billed charges CALCIUM; TOTAL 3018231001_1 CDM 301 RC 82310 HCPCS outpatient 56 42 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 49.84 89 999999999 43.68 53.2 percent of total billed charges CALCIUM; TOTAL 3018231001_1 CDM 301 RC 82310 HCPCS outpatient 56 42 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50.4 90 999999999 43.68 53.2 percent of total billed charges CALCIUM; TOTAL 3018231001_1 CDM 301 RC 82310 HCPCS outpatient 56 42 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 53.2 95 999999999 43.68 53.2 percent of total billed charges CALCIUM; TOTAL 3018231001_1 CDM 301 RC 82310 HCPCS outpatient 56 42 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 53.2 95 999999999 43.68 53.2 percent of total billed charges CALCIUM; TOTAL 3018231001_1 CDM 301 RC 82310 HCPCS outpatient 56 42 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 49.84 89 999999999 43.68 53.2 percent of total billed charges CALCIUM; TOTAL 3018231001_1 CDM 301 RC 82310 HCPCS outpatient 56 42 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 49.28 88 999999999 43.68 53.2 percent of total billed charges CALCIUM; TOTAL 3018231001_1 CDM 301 RC 82310 HCPCS outpatient 56 42 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 49.84 89 999999999 43.68 53.2 percent of total billed charges CALCIUM; IONIZED 3018233003_1 CDM 301 RC 82330 HCPCS outpatient 124 93 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 111.6 90 999999999 96.72 117.8 percent of total billed charges CALCIUM; IONIZED 3018233003_1 CDM 301 RC 82330 HCPCS outpatient 124 93 AETNA MCR ADV AETNA MCR ADV 96.72 78 999999999 96.72 117.8 percent of total billed charges CALCIUM; IONIZED 3018233003_1 CDM 301 RC 82330 HCPCS outpatient 124 93 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 108.59 87.57 999999999 96.72 117.8 percent of total billed charges CALCIUM; IONIZED 3018233003_1 CDM 301 RC 82330 HCPCS outpatient 124 93 COORDINATED CARE MCAID COORDINATED CARE MCAID 105.49 85.07 999999999 96.72 117.8 percent of total billed charges CALCIUM; IONIZED 3018233003_1 CDM 301 RC 82330 HCPCS outpatient 124 93 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 105.49 85.07 999999999 96.72 117.8 percent of total billed charges CALCIUM; IONIZED 3018233003_1 CDM 301 RC 82330 HCPCS outpatient 124 93 MOLINA MCAID MOLINA MCAID 103.42 83.4 999999999 96.72 117.8 percent of total billed charges CALCIUM; IONIZED 3018233003_1 CDM 301 RC 82330 HCPCS outpatient 124 93 MOLINA MCR ADV MOLINA MCR ADV 110.36 89 999999999 96.72 117.8 percent of total billed charges CALCIUM; IONIZED 3018233003_1 CDM 301 RC 82330 HCPCS outpatient 124 93 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 110.36 89 999999999 96.72 117.8 percent of total billed charges CALCIUM; IONIZED 3018233003_1 CDM 301 RC 82330 HCPCS outpatient 124 93 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 110.36 89 999999999 96.72 117.8 percent of total billed charges CALCIUM; IONIZED 3018233003_1 CDM 301 RC 82330 HCPCS outpatient 124 93 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 111.6 90 999999999 96.72 117.8 percent of total billed charges CALCIUM; IONIZED 3018233003_1 CDM 301 RC 82330 HCPCS outpatient 124 93 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 117.8 95 999999999 96.72 117.8 percent of total billed charges CALCIUM; IONIZED 3018233003_1 CDM 301 RC 82330 HCPCS outpatient 124 93 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 117.8 95 999999999 96.72 117.8 percent of total billed charges CALCIUM; IONIZED 3018233003_1 CDM 301 RC 82330 HCPCS outpatient 124 93 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 110.36 89 999999999 96.72 117.8 percent of total billed charges CALCIUM; IONIZED 3018233003_1 CDM 301 RC 82330 HCPCS outpatient 124 93 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 109.12 88 999999999 96.72 117.8 percent of total billed charges CALCIUM; IONIZED 3018233003_1 CDM 301 RC 82330 HCPCS outpatient 124 93 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 110.36 89 999999999 96.72 117.8 percent of total billed charges "CALCIUM; URINE QUANTITATIVE, TIMED SPECIMEN" 3018234001_1 CDM 301 RC 82340 HCPCS outpatient 77 57.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 69.3 90 999999999 60.06 73.15 percent of total billed charges "CALCIUM; URINE QUANTITATIVE, TIMED SPECIMEN" 3018234001_1 CDM 301 RC 82340 HCPCS outpatient 77 57.75 AETNA MCR ADV AETNA MCR ADV 60.06 78 999999999 60.06 73.15 percent of total billed charges "CALCIUM; URINE QUANTITATIVE, TIMED SPECIMEN" 3018234001_1 CDM 301 RC 82340 HCPCS outpatient 77 57.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 67.43 87.57 999999999 60.06 73.15 percent of total billed charges "CALCIUM; URINE QUANTITATIVE, TIMED SPECIMEN" 3018234001_1 CDM 301 RC 82340 HCPCS outpatient 77 57.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 65.5 85.07 999999999 60.06 73.15 percent of total billed charges "CALCIUM; URINE QUANTITATIVE, TIMED SPECIMEN" 3018234001_1 CDM 301 RC 82340 HCPCS outpatient 77 57.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 65.5 85.07 999999999 60.06 73.15 percent of total billed charges "CALCIUM; URINE QUANTITATIVE, TIMED SPECIMEN" 3018234001_1 CDM 301 RC 82340 HCPCS outpatient 77 57.75 MOLINA MCAID MOLINA MCAID 64.22 83.4 999999999 60.06 73.15 percent of total billed charges "CALCIUM; URINE QUANTITATIVE, TIMED SPECIMEN" 3018234001_1 CDM 301 RC 82340 HCPCS outpatient 77 57.75 MOLINA MCR ADV MOLINA MCR ADV 68.53 89 999999999 60.06 73.15 percent of total billed charges "CALCIUM; URINE QUANTITATIVE, TIMED SPECIMEN" 3018234001_1 CDM 301 RC 82340 HCPCS outpatient 77 57.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 68.53 89 999999999 60.06 73.15 percent of total billed charges "CALCIUM; URINE QUANTITATIVE, TIMED SPECIMEN" 3018234001_1 CDM 301 RC 82340 HCPCS outpatient 77 57.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 68.53 89 999999999 60.06 73.15 percent of total billed charges "CALCIUM; URINE QUANTITATIVE, TIMED SPECIMEN" 3018234001_1 CDM 301 RC 82340 HCPCS outpatient 77 57.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 69.3 90 999999999 60.06 73.15 percent of total billed charges "CALCIUM; URINE QUANTITATIVE, TIMED SPECIMEN" 3018234001_1 CDM 301 RC 82340 HCPCS outpatient 77 57.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 73.15 95 999999999 60.06 73.15 percent of total billed charges "CALCIUM; URINE QUANTITATIVE, TIMED SPECIMEN" 3018234001_1 CDM 301 RC 82340 HCPCS outpatient 77 57.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 73.15 95 999999999 60.06 73.15 percent of total billed charges "CALCIUM; URINE QUANTITATIVE, TIMED SPECIMEN" 3018234001_1 CDM 301 RC 82340 HCPCS outpatient 77 57.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 68.53 89 999999999 60.06 73.15 percent of total billed charges "CALCIUM; URINE QUANTITATIVE, TIMED SPECIMEN" 3018234001_1 CDM 301 RC 82340 HCPCS outpatient 77 57.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 67.76 88 999999999 60.06 73.15 percent of total billed charges "CALCIUM; URINE QUANTITATIVE, TIMED SPECIMEN" 3018234001_1 CDM 301 RC 82340 HCPCS outpatient 77 57.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 68.53 89 999999999 60.06 73.15 percent of total billed charges CALCULUS; INFRARED SPECTROSCOPY 3018236502_1 CDM 301 RC 82365 HCPCS outpatient 132 99 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 118.8 90 999999999 102.96 125.4 percent of total billed charges CALCULUS; INFRARED SPECTROSCOPY 3018236502_1 CDM 301 RC 82365 HCPCS outpatient 132 99 AETNA MCR ADV AETNA MCR ADV 102.96 78 999999999 102.96 125.4 percent of total billed charges CALCULUS; INFRARED SPECTROSCOPY 3018236502_1 CDM 301 RC 82365 HCPCS outpatient 132 99 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 115.59 87.57 999999999 102.96 125.4 percent of total billed charges CALCULUS; INFRARED SPECTROSCOPY 3018236502_1 CDM 301 RC 82365 HCPCS outpatient 132 99 COORDINATED CARE MCAID COORDINATED CARE MCAID 112.29 85.07 999999999 102.96 125.4 percent of total billed charges CALCULUS; INFRARED SPECTROSCOPY 3018236502_1 CDM 301 RC 82365 HCPCS outpatient 132 99 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 112.29 85.07 999999999 102.96 125.4 percent of total billed charges CALCULUS; INFRARED SPECTROSCOPY 3018236502_1 CDM 301 RC 82365 HCPCS outpatient 132 99 MOLINA MCAID MOLINA MCAID 110.09 83.4 999999999 102.96 125.4 percent of total billed charges CALCULUS; INFRARED SPECTROSCOPY 3018236502_1 CDM 301 RC 82365 HCPCS outpatient 132 99 MOLINA MCR ADV MOLINA MCR ADV 117.48 89 999999999 102.96 125.4 percent of total billed charges CALCULUS; INFRARED SPECTROSCOPY 3018236502_1 CDM 301 RC 82365 HCPCS outpatient 132 99 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 117.48 89 999999999 102.96 125.4 percent of total billed charges CALCULUS; INFRARED SPECTROSCOPY 3018236502_1 CDM 301 RC 82365 HCPCS outpatient 132 99 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 117.48 89 999999999 102.96 125.4 percent of total billed charges CALCULUS; INFRARED SPECTROSCOPY 3018236502_1 CDM 301 RC 82365 HCPCS outpatient 132 99 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 118.8 90 999999999 102.96 125.4 percent of total billed charges CALCULUS; INFRARED SPECTROSCOPY 3018236502_1 CDM 301 RC 82365 HCPCS outpatient 132 99 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 125.4 95 999999999 102.96 125.4 percent of total billed charges CALCULUS; INFRARED SPECTROSCOPY 3018236502_1 CDM 301 RC 82365 HCPCS outpatient 132 99 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 125.4 95 999999999 102.96 125.4 percent of total billed charges CALCULUS; INFRARED SPECTROSCOPY 3018236502_1 CDM 301 RC 82365 HCPCS outpatient 132 99 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 117.48 89 999999999 102.96 125.4 percent of total billed charges CALCULUS; INFRARED SPECTROSCOPY 3018236502_1 CDM 301 RC 82365 HCPCS outpatient 132 99 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 116.16 88 999999999 102.96 125.4 percent of total billed charges CALCULUS; INFRARED SPECTROSCOPY 3018236502_1 CDM 301 RC 82365 HCPCS outpatient 132 99 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 117.48 89 999999999 102.96 125.4 percent of total billed charges CARBON DIOXIDE (BICARBONATE) 3018237401_1 CDM 301 RC 82374 HCPCS outpatient 63 47.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 56.7 90 999999999 49.14 59.85 percent of total billed charges CARBON DIOXIDE (BICARBONATE) 3018237401_1 CDM 301 RC 82374 HCPCS outpatient 63 47.25 AETNA MCR ADV AETNA MCR ADV 49.14 78 999999999 49.14 59.85 percent of total billed charges CARBON DIOXIDE (BICARBONATE) 3018237401_1 CDM 301 RC 82374 HCPCS outpatient 63 47.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 55.17 87.57 999999999 49.14 59.85 percent of total billed charges CARBON DIOXIDE (BICARBONATE) 3018237401_1 CDM 301 RC 82374 HCPCS outpatient 63 47.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 53.59 85.07 999999999 49.14 59.85 percent of total billed charges CARBON DIOXIDE (BICARBONATE) 3018237401_1 CDM 301 RC 82374 HCPCS outpatient 63 47.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 53.59 85.07 999999999 49.14 59.85 percent of total billed charges CARBON DIOXIDE (BICARBONATE) 3018237401_1 CDM 301 RC 82374 HCPCS outpatient 63 47.25 MOLINA MCAID MOLINA MCAID 52.54 83.4 999999999 49.14 59.85 percent of total billed charges CARBON DIOXIDE (BICARBONATE) 3018237401_1 CDM 301 RC 82374 HCPCS outpatient 63 47.25 MOLINA MCR ADV MOLINA MCR ADV 56.07 89 999999999 49.14 59.85 percent of total billed charges CARBON DIOXIDE (BICARBONATE) 3018237401_1 CDM 301 RC 82374 HCPCS outpatient 63 47.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 56.07 89 999999999 49.14 59.85 percent of total billed charges CARBON DIOXIDE (BICARBONATE) 3018237401_1 CDM 301 RC 82374 HCPCS outpatient 63 47.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 56.07 89 999999999 49.14 59.85 percent of total billed charges CARBON DIOXIDE (BICARBONATE) 3018237401_1 CDM 301 RC 82374 HCPCS outpatient 63 47.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 56.7 90 999999999 49.14 59.85 percent of total billed charges CARBON DIOXIDE (BICARBONATE) 3018237401_1 CDM 301 RC 82374 HCPCS outpatient 63 47.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 59.85 95 999999999 49.14 59.85 percent of total billed charges CARBON DIOXIDE (BICARBONATE) 3018237401_1 CDM 301 RC 82374 HCPCS outpatient 63 47.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 59.85 95 999999999 49.14 59.85 percent of total billed charges CARBON DIOXIDE (BICARBONATE) 3018237401_1 CDM 301 RC 82374 HCPCS outpatient 63 47.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 56.07 89 999999999 49.14 59.85 percent of total billed charges CARBON DIOXIDE (BICARBONATE) 3018237401_1 CDM 301 RC 82374 HCPCS outpatient 63 47.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 55.44 88 999999999 49.14 59.85 percent of total billed charges CARBON DIOXIDE (BICARBONATE) 3018237401_1 CDM 301 RC 82374 HCPCS outpatient 63 47.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 56.07 89 999999999 49.14 59.85 percent of total billed charges CARBOXYHEMOGLOBIN; QUANTITATIVE 3018237501_1 CDM 301 RC 82375 HCPCS outpatient 58 43.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 52.2 90 999999999 45.24 55.1 percent of total billed charges CARBOXYHEMOGLOBIN; QUANTITATIVE 3018237501_1 CDM 301 RC 82375 HCPCS outpatient 58 43.5 AETNA MCR ADV AETNA MCR ADV 45.24 78 999999999 45.24 55.1 percent of total billed charges CARBOXYHEMOGLOBIN; QUANTITATIVE 3018237501_1 CDM 301 RC 82375 HCPCS outpatient 58 43.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50.79 87.57 999999999 45.24 55.1 percent of total billed charges CARBOXYHEMOGLOBIN; QUANTITATIVE 3018237501_1 CDM 301 RC 82375 HCPCS outpatient 58 43.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 49.34 85.07 999999999 45.24 55.1 percent of total billed charges CARBOXYHEMOGLOBIN; QUANTITATIVE 3018237501_1 CDM 301 RC 82375 HCPCS outpatient 58 43.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 49.34 85.07 999999999 45.24 55.1 percent of total billed charges CARBOXYHEMOGLOBIN; QUANTITATIVE 3018237501_1 CDM 301 RC 82375 HCPCS outpatient 58 43.5 MOLINA MCAID MOLINA MCAID 48.37 83.4 999999999 45.24 55.1 percent of total billed charges CARBOXYHEMOGLOBIN; QUANTITATIVE 3018237501_1 CDM 301 RC 82375 HCPCS outpatient 58 43.5 MOLINA MCR ADV MOLINA MCR ADV 51.62 89 999999999 45.24 55.1 percent of total billed charges CARBOXYHEMOGLOBIN; QUANTITATIVE 3018237501_1 CDM 301 RC 82375 HCPCS outpatient 58 43.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 51.62 89 999999999 45.24 55.1 percent of total billed charges CARBOXYHEMOGLOBIN; QUANTITATIVE 3018237501_1 CDM 301 RC 82375 HCPCS outpatient 58 43.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 51.62 89 999999999 45.24 55.1 percent of total billed charges CARBOXYHEMOGLOBIN; QUANTITATIVE 3018237501_1 CDM 301 RC 82375 HCPCS outpatient 58 43.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 52.2 90 999999999 45.24 55.1 percent of total billed charges CARBOXYHEMOGLOBIN; QUANTITATIVE 3018237501_1 CDM 301 RC 82375 HCPCS outpatient 58 43.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 55.1 95 999999999 45.24 55.1 percent of total billed charges CARBOXYHEMOGLOBIN; QUANTITATIVE 3018237501_1 CDM 301 RC 82375 HCPCS outpatient 58 43.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 55.1 95 999999999 45.24 55.1 percent of total billed charges CARBOXYHEMOGLOBIN; QUANTITATIVE 3018237501_1 CDM 301 RC 82375 HCPCS outpatient 58 43.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 51.62 89 999999999 45.24 55.1 percent of total billed charges CARBOXYHEMOGLOBIN; QUANTITATIVE 3018237501_1 CDM 301 RC 82375 HCPCS outpatient 58 43.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 51.04 88 999999999 45.24 55.1 percent of total billed charges CARBOXYHEMOGLOBIN; QUANTITATIVE 3018237501_1 CDM 301 RC 82375 HCPCS outpatient 58 43.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 51.62 89 999999999 45.24 55.1 percent of total billed charges CARCINOEMBRYONIC ANTIGEN (CEA) 3018237801_1 CDM 301 RC 82378 HCPCS outpatient 155 116.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 139.5 90 999999999 120.9 147.25 percent of total billed charges CARCINOEMBRYONIC ANTIGEN (CEA) 3018237801_1 CDM 301 RC 82378 HCPCS outpatient 155 116.25 AETNA MCR ADV AETNA MCR ADV 120.9 78 999999999 120.9 147.25 percent of total billed charges CARCINOEMBRYONIC ANTIGEN (CEA) 3018237801_1 CDM 301 RC 82378 HCPCS outpatient 155 116.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 135.73 87.57 999999999 120.9 147.25 percent of total billed charges CARCINOEMBRYONIC ANTIGEN (CEA) 3018237801_1 CDM 301 RC 82378 HCPCS outpatient 155 116.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 131.86 85.07 999999999 120.9 147.25 percent of total billed charges CARCINOEMBRYONIC ANTIGEN (CEA) 3018237801_1 CDM 301 RC 82378 HCPCS outpatient 155 116.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 131.86 85.07 999999999 120.9 147.25 percent of total billed charges CARCINOEMBRYONIC ANTIGEN (CEA) 3018237801_1 CDM 301 RC 82378 HCPCS outpatient 155 116.25 MOLINA MCAID MOLINA MCAID 129.27 83.4 999999999 120.9 147.25 percent of total billed charges CARCINOEMBRYONIC ANTIGEN (CEA) 3018237801_1 CDM 301 RC 82378 HCPCS outpatient 155 116.25 MOLINA MCR ADV MOLINA MCR ADV 137.95 89 999999999 120.9 147.25 percent of total billed charges CARCINOEMBRYONIC ANTIGEN (CEA) 3018237801_1 CDM 301 RC 82378 HCPCS outpatient 155 116.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 137.95 89 999999999 120.9 147.25 percent of total billed charges CARCINOEMBRYONIC ANTIGEN (CEA) 3018237801_1 CDM 301 RC 82378 HCPCS outpatient 155 116.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 137.95 89 999999999 120.9 147.25 percent of total billed charges CARCINOEMBRYONIC ANTIGEN (CEA) 3018237801_1 CDM 301 RC 82378 HCPCS outpatient 155 116.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 139.5 90 999999999 120.9 147.25 percent of total billed charges CARCINOEMBRYONIC ANTIGEN (CEA) 3018237801_1 CDM 301 RC 82378 HCPCS outpatient 155 116.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 147.25 95 999999999 120.9 147.25 percent of total billed charges CARCINOEMBRYONIC ANTIGEN (CEA) 3018237801_1 CDM 301 RC 82378 HCPCS outpatient 155 116.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 147.25 95 999999999 120.9 147.25 percent of total billed charges CARCINOEMBRYONIC ANTIGEN (CEA) 3018237801_1 CDM 301 RC 82378 HCPCS outpatient 155 116.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 137.95 89 999999999 120.9 147.25 percent of total billed charges CARCINOEMBRYONIC ANTIGEN (CEA) 3018237801_1 CDM 301 RC 82378 HCPCS outpatient 155 116.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 136.4 88 999999999 120.9 147.25 percent of total billed charges CARCINOEMBRYONIC ANTIGEN (CEA) 3018237801_1 CDM 301 RC 82378 HCPCS outpatient 155 116.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 137.95 89 999999999 120.9 147.25 percent of total billed charges CAROTENE 3018238001_1 CDM 301 RC 82380 HCPCS outpatient 260 195 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 234 90 999999999 202.8 247 percent of total billed charges CAROTENE 3018238001_1 CDM 301 RC 82380 HCPCS outpatient 260 195 AETNA MCR ADV AETNA MCR ADV 202.8 78 999999999 202.8 247 percent of total billed charges CAROTENE 3018238001_1 CDM 301 RC 82380 HCPCS outpatient 260 195 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 227.68 87.57 999999999 202.8 247 percent of total billed charges CAROTENE 3018238001_1 CDM 301 RC 82380 HCPCS outpatient 260 195 COORDINATED CARE MCAID COORDINATED CARE MCAID 221.18 85.07 999999999 202.8 247 percent of total billed charges CAROTENE 3018238001_1 CDM 301 RC 82380 HCPCS outpatient 260 195 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 221.18 85.07 999999999 202.8 247 percent of total billed charges CAROTENE 3018238001_1 CDM 301 RC 82380 HCPCS outpatient 260 195 MOLINA MCAID MOLINA MCAID 216.84 83.4 999999999 202.8 247 percent of total billed charges CAROTENE 3018238001_1 CDM 301 RC 82380 HCPCS outpatient 260 195 MOLINA MCR ADV MOLINA MCR ADV 231.4 89 999999999 202.8 247 percent of total billed charges CAROTENE 3018238001_1 CDM 301 RC 82380 HCPCS outpatient 260 195 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 231.4 89 999999999 202.8 247 percent of total billed charges CAROTENE 3018238001_1 CDM 301 RC 82380 HCPCS outpatient 260 195 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 231.4 89 999999999 202.8 247 percent of total billed charges CAROTENE 3018238001_1 CDM 301 RC 82380 HCPCS outpatient 260 195 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 234 90 999999999 202.8 247 percent of total billed charges CAROTENE 3018238001_1 CDM 301 RC 82380 HCPCS outpatient 260 195 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 247 95 999999999 202.8 247 percent of total billed charges CAROTENE 3018238001_1 CDM 301 RC 82380 HCPCS outpatient 260 195 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 247 95 999999999 202.8 247 percent of total billed charges CAROTENE 3018238001_1 CDM 301 RC 82380 HCPCS outpatient 260 195 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 231.4 89 999999999 202.8 247 percent of total billed charges CAROTENE 3018238001_1 CDM 301 RC 82380 HCPCS outpatient 260 195 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 228.8 88 999999999 202.8 247 percent of total billed charges CAROTENE 3018238001_1 CDM 301 RC 82380 HCPCS outpatient 260 195 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 231.4 89 999999999 202.8 247 percent of total billed charges CHLORIDE; BLOOD 3018243502_1 CDM 301 RC 82435 HCPCS outpatient 32 24 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 28.8 90 999999999 24.96 30.4 percent of total billed charges CHLORIDE; BLOOD 3018243502_1 CDM 301 RC 82435 HCPCS outpatient 32 24 AETNA MCR ADV AETNA MCR ADV 24.96 78 999999999 24.96 30.4 percent of total billed charges CHLORIDE; BLOOD 3018243502_1 CDM 301 RC 82435 HCPCS outpatient 32 24 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 28.02 87.57 999999999 24.96 30.4 percent of total billed charges CHLORIDE; BLOOD 3018243502_1 CDM 301 RC 82435 HCPCS outpatient 32 24 COORDINATED CARE MCAID COORDINATED CARE MCAID 27.22 85.07 999999999 24.96 30.4 percent of total billed charges CHLORIDE; BLOOD 3018243502_1 CDM 301 RC 82435 HCPCS outpatient 32 24 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 27.22 85.07 999999999 24.96 30.4 percent of total billed charges CHLORIDE; BLOOD 3018243502_1 CDM 301 RC 82435 HCPCS outpatient 32 24 MOLINA MCAID MOLINA MCAID 26.69 83.4 999999999 24.96 30.4 percent of total billed charges CHLORIDE; BLOOD 3018243502_1 CDM 301 RC 82435 HCPCS outpatient 32 24 MOLINA MCR ADV MOLINA MCR ADV 28.48 89 999999999 24.96 30.4 percent of total billed charges CHLORIDE; BLOOD 3018243502_1 CDM 301 RC 82435 HCPCS outpatient 32 24 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 28.48 89 999999999 24.96 30.4 percent of total billed charges CHLORIDE; BLOOD 3018243502_1 CDM 301 RC 82435 HCPCS outpatient 32 24 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 28.48 89 999999999 24.96 30.4 percent of total billed charges CHLORIDE; BLOOD 3018243502_1 CDM 301 RC 82435 HCPCS outpatient 32 24 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 28.8 90 999999999 24.96 30.4 percent of total billed charges CHLORIDE; BLOOD 3018243502_1 CDM 301 RC 82435 HCPCS outpatient 32 24 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 30.4 95 999999999 24.96 30.4 percent of total billed charges CHLORIDE; BLOOD 3018243502_1 CDM 301 RC 82435 HCPCS outpatient 32 24 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 30.4 95 999999999 24.96 30.4 percent of total billed charges CHLORIDE; BLOOD 3018243502_1 CDM 301 RC 82435 HCPCS outpatient 32 24 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 28.48 89 999999999 24.96 30.4 percent of total billed charges CHLORIDE; BLOOD 3018243502_1 CDM 301 RC 82435 HCPCS outpatient 32 24 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 28.16 88 999999999 24.96 30.4 percent of total billed charges CHLORIDE; BLOOD 3018243502_1 CDM 301 RC 82435 HCPCS outpatient 32 24 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 28.48 89 999999999 24.96 30.4 percent of total billed charges "CHOLESTEROL, SERUM OR WHOLE BLOOD, TOTAL" 3018246501_1 CDM 301 RC 82465 HCPCS outpatient 26 19.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 23.4 90 999999999 20.28 24.7 percent of total billed charges "CHOLESTEROL, SERUM OR WHOLE BLOOD, TOTAL" 3018246501_1 CDM 301 RC 82465 HCPCS outpatient 26 19.5 AETNA MCR ADV AETNA MCR ADV 20.28 78 999999999 20.28 24.7 percent of total billed charges "CHOLESTEROL, SERUM OR WHOLE BLOOD, TOTAL" 3018246501_1 CDM 301 RC 82465 HCPCS outpatient 26 19.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 22.77 87.57 999999999 20.28 24.7 percent of total billed charges "CHOLESTEROL, SERUM OR WHOLE BLOOD, TOTAL" 3018246501_1 CDM 301 RC 82465 HCPCS outpatient 26 19.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 22.12 85.07 999999999 20.28 24.7 percent of total billed charges "CHOLESTEROL, SERUM OR WHOLE BLOOD, TOTAL" 3018246501_1 CDM 301 RC 82465 HCPCS outpatient 26 19.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 22.12 85.07 999999999 20.28 24.7 percent of total billed charges "CHOLESTEROL, SERUM OR WHOLE BLOOD, TOTAL" 3018246501_1 CDM 301 RC 82465 HCPCS outpatient 26 19.5 MOLINA MCAID MOLINA MCAID 21.68 83.4 999999999 20.28 24.7 percent of total billed charges "CHOLESTEROL, SERUM OR WHOLE BLOOD, TOTAL" 3018246501_1 CDM 301 RC 82465 HCPCS outpatient 26 19.5 MOLINA MCR ADV MOLINA MCR ADV 23.14 89 999999999 20.28 24.7 percent of total billed charges "CHOLESTEROL, SERUM OR WHOLE BLOOD, TOTAL" 3018246501_1 CDM 301 RC 82465 HCPCS outpatient 26 19.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 23.14 89 999999999 20.28 24.7 percent of total billed charges "CHOLESTEROL, SERUM OR WHOLE BLOOD, TOTAL" 3018246501_1 CDM 301 RC 82465 HCPCS outpatient 26 19.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 23.14 89 999999999 20.28 24.7 percent of total billed charges "CHOLESTEROL, SERUM OR WHOLE BLOOD, TOTAL" 3018246501_1 CDM 301 RC 82465 HCPCS outpatient 26 19.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 23.4 90 999999999 20.28 24.7 percent of total billed charges "CHOLESTEROL, SERUM OR WHOLE BLOOD, TOTAL" 3018246501_1 CDM 301 RC 82465 HCPCS outpatient 26 19.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 24.7 95 999999999 20.28 24.7 percent of total billed charges "CHOLESTEROL, SERUM OR WHOLE BLOOD, TOTAL" 3018246501_1 CDM 301 RC 82465 HCPCS outpatient 26 19.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 24.7 95 999999999 20.28 24.7 percent of total billed charges "CHOLESTEROL, SERUM OR WHOLE BLOOD, TOTAL" 3018246501_1 CDM 301 RC 82465 HCPCS outpatient 26 19.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 23.14 89 999999999 20.28 24.7 percent of total billed charges "CHOLESTEROL, SERUM OR WHOLE BLOOD, TOTAL" 3018246501_1 CDM 301 RC 82465 HCPCS outpatient 26 19.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 22.88 88 999999999 20.28 24.7 percent of total billed charges "CHOLESTEROL, SERUM OR WHOLE BLOOD, TOTAL" 3018246501_1 CDM 301 RC 82465 HCPCS outpatient 26 19.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 23.14 89 999999999 20.28 24.7 percent of total billed charges CORTISOL; TOTAL 3018253301_1 CDM 301 RC 82533 HCPCS outpatient 115 86.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 103.5 90 999999999 89.7 109.25 percent of total billed charges CORTISOL; TOTAL 3018253301_1 CDM 301 RC 82533 HCPCS outpatient 115 86.25 AETNA MCR ADV AETNA MCR ADV 89.7 78 999999999 89.7 109.25 percent of total billed charges CORTISOL; TOTAL 3018253301_1 CDM 301 RC 82533 HCPCS outpatient 115 86.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 100.71 87.57 999999999 89.7 109.25 percent of total billed charges CORTISOL; TOTAL 3018253301_1 CDM 301 RC 82533 HCPCS outpatient 115 86.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 97.83 85.07 999999999 89.7 109.25 percent of total billed charges CORTISOL; TOTAL 3018253301_1 CDM 301 RC 82533 HCPCS outpatient 115 86.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 97.83 85.07 999999999 89.7 109.25 percent of total billed charges CORTISOL; TOTAL 3018253301_1 CDM 301 RC 82533 HCPCS outpatient 115 86.25 MOLINA MCAID MOLINA MCAID 95.91 83.4 999999999 89.7 109.25 percent of total billed charges CORTISOL; TOTAL 3018253301_1 CDM 301 RC 82533 HCPCS outpatient 115 86.25 MOLINA MCR ADV MOLINA MCR ADV 102.35 89 999999999 89.7 109.25 percent of total billed charges CORTISOL; TOTAL 3018253301_1 CDM 301 RC 82533 HCPCS outpatient 115 86.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 102.35 89 999999999 89.7 109.25 percent of total billed charges CORTISOL; TOTAL 3018253301_1 CDM 301 RC 82533 HCPCS outpatient 115 86.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 102.35 89 999999999 89.7 109.25 percent of total billed charges CORTISOL; TOTAL 3018253301_1 CDM 301 RC 82533 HCPCS outpatient 115 86.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 103.5 90 999999999 89.7 109.25 percent of total billed charges CORTISOL; TOTAL 3018253301_1 CDM 301 RC 82533 HCPCS outpatient 115 86.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 109.25 95 999999999 89.7 109.25 percent of total billed charges CORTISOL; TOTAL 3018253301_1 CDM 301 RC 82533 HCPCS outpatient 115 86.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 109.25 95 999999999 89.7 109.25 percent of total billed charges CORTISOL; TOTAL 3018253301_1 CDM 301 RC 82533 HCPCS outpatient 115 86.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 102.35 89 999999999 89.7 109.25 percent of total billed charges CORTISOL; TOTAL 3018253301_1 CDM 301 RC 82533 HCPCS outpatient 115 86.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 101.2 88 999999999 89.7 109.25 percent of total billed charges CORTISOL; TOTAL 3018253301_1 CDM 301 RC 82533 HCPCS outpatient 115 86.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 102.35 89 999999999 89.7 109.25 percent of total billed charges "CREATINE KINASE (CK), (CPK); TOTAL" 3018255001_1 CDM 301 RC 82550 HCPCS outpatient 100 75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 90 90 999999999 78 95 percent of total billed charges "CREATINE KINASE (CK), (CPK); TOTAL" 3018255001_1 CDM 301 RC 82550 HCPCS outpatient 100 75 AETNA MCR ADV AETNA MCR ADV 78 78 999999999 78 95 percent of total billed charges "CREATINE KINASE (CK), (CPK); TOTAL" 3018255001_1 CDM 301 RC 82550 HCPCS outpatient 100 75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 87.57 87.57 999999999 78 95 percent of total billed charges "CREATINE KINASE (CK), (CPK); TOTAL" 3018255001_1 CDM 301 RC 82550 HCPCS outpatient 100 75 COORDINATED CARE MCAID COORDINATED CARE MCAID 85.07 85.07 999999999 78 95 percent of total billed charges "CREATINE KINASE (CK), (CPK); TOTAL" 3018255001_1 CDM 301 RC 82550 HCPCS outpatient 100 75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 85.07 85.07 999999999 78 95 percent of total billed charges "CREATINE KINASE (CK), (CPK); TOTAL" 3018255001_1 CDM 301 RC 82550 HCPCS outpatient 100 75 MOLINA MCAID MOLINA MCAID 83.4 83.4 999999999 78 95 percent of total billed charges "CREATINE KINASE (CK), (CPK); TOTAL" 3018255001_1 CDM 301 RC 82550 HCPCS outpatient 100 75 MOLINA MCR ADV MOLINA MCR ADV 89 89 999999999 78 95 percent of total billed charges "CREATINE KINASE (CK), (CPK); TOTAL" 3018255001_1 CDM 301 RC 82550 HCPCS outpatient 100 75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 89 89 999999999 78 95 percent of total billed charges "CREATINE KINASE (CK), (CPK); TOTAL" 3018255001_1 CDM 301 RC 82550 HCPCS outpatient 100 75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 89 89 999999999 78 95 percent of total billed charges "CREATINE KINASE (CK), (CPK); TOTAL" 3018255001_1 CDM 301 RC 82550 HCPCS outpatient 100 75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 90 90 999999999 78 95 percent of total billed charges "CREATINE KINASE (CK), (CPK); TOTAL" 3018255001_1 CDM 301 RC 82550 HCPCS outpatient 100 75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 95 95 999999999 78 95 percent of total billed charges "CREATINE KINASE (CK), (CPK); TOTAL" 3018255001_1 CDM 301 RC 82550 HCPCS outpatient 100 75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 95 95 999999999 78 95 percent of total billed charges "CREATINE KINASE (CK), (CPK); TOTAL" 3018255001_1 CDM 301 RC 82550 HCPCS outpatient 100 75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 89 89 999999999 78 95 percent of total billed charges "CREATINE KINASE (CK), (CPK); TOTAL" 3018255001_1 CDM 301 RC 82550 HCPCS outpatient 100 75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 88 88 999999999 78 95 percent of total billed charges "CREATINE KINASE (CK), (CPK); TOTAL" 3018255001_1 CDM 301 RC 82550 HCPCS outpatient 100 75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 89 89 999999999 78 95 percent of total billed charges "CREATINE KINASE (CK), (CPK); MB FRACTION ONLY" 3018255301_1 CDM 301 RC 82553 HCPCS outpatient 156 117 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 140.4 90 999999999 121.68 148.2 percent of total billed charges "CREATINE KINASE (CK), (CPK); MB FRACTION ONLY" 3018255301_1 CDM 301 RC 82553 HCPCS outpatient 156 117 AETNA MCR ADV AETNA MCR ADV 121.68 78 999999999 121.68 148.2 percent of total billed charges "CREATINE KINASE (CK), (CPK); MB FRACTION ONLY" 3018255301_1 CDM 301 RC 82553 HCPCS outpatient 156 117 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 136.61 87.57 999999999 121.68 148.2 percent of total billed charges "CREATINE KINASE (CK), (CPK); MB FRACTION ONLY" 3018255301_1 CDM 301 RC 82553 HCPCS outpatient 156 117 COORDINATED CARE MCAID COORDINATED CARE MCAID 132.71 85.07 999999999 121.68 148.2 percent of total billed charges "CREATINE KINASE (CK), (CPK); MB FRACTION ONLY" 3018255301_1 CDM 301 RC 82553 HCPCS outpatient 156 117 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 132.71 85.07 999999999 121.68 148.2 percent of total billed charges "CREATINE KINASE (CK), (CPK); MB FRACTION ONLY" 3018255301_1 CDM 301 RC 82553 HCPCS outpatient 156 117 MOLINA MCAID MOLINA MCAID 130.1 83.4 999999999 121.68 148.2 percent of total billed charges "CREATINE KINASE (CK), (CPK); MB FRACTION ONLY" 3018255301_1 CDM 301 RC 82553 HCPCS outpatient 156 117 MOLINA MCR ADV MOLINA MCR ADV 138.84 89 999999999 121.68 148.2 percent of total billed charges "CREATINE KINASE (CK), (CPK); MB FRACTION ONLY" 3018255301_1 CDM 301 RC 82553 HCPCS outpatient 156 117 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 138.84 89 999999999 121.68 148.2 percent of total billed charges "CREATINE KINASE (CK), (CPK); MB FRACTION ONLY" 3018255301_1 CDM 301 RC 82553 HCPCS outpatient 156 117 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 138.84 89 999999999 121.68 148.2 percent of total billed charges "CREATINE KINASE (CK), (CPK); MB FRACTION ONLY" 3018255301_1 CDM 301 RC 82553 HCPCS outpatient 156 117 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 140.4 90 999999999 121.68 148.2 percent of total billed charges "CREATINE KINASE (CK), (CPK); MB FRACTION ONLY" 3018255301_1 CDM 301 RC 82553 HCPCS outpatient 156 117 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 148.2 95 999999999 121.68 148.2 percent of total billed charges "CREATINE KINASE (CK), (CPK); MB FRACTION ONLY" 3018255301_1 CDM 301 RC 82553 HCPCS outpatient 156 117 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 148.2 95 999999999 121.68 148.2 percent of total billed charges "CREATINE KINASE (CK), (CPK); MB FRACTION ONLY" 3018255301_1 CDM 301 RC 82553 HCPCS outpatient 156 117 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 138.84 89 999999999 121.68 148.2 percent of total billed charges "CREATINE KINASE (CK), (CPK); MB FRACTION ONLY" 3018255301_1 CDM 301 RC 82553 HCPCS outpatient 156 117 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 137.28 88 999999999 121.68 148.2 percent of total billed charges "CREATINE KINASE (CK), (CPK); MB FRACTION ONLY" 3018255301_1 CDM 301 RC 82553 HCPCS outpatient 156 117 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 138.84 89 999999999 121.68 148.2 percent of total billed charges CREATININE; BLOOD 3018256501_1 CDM 301 RC 82565 HCPCS outpatient 59 44.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 53.1 90 999999999 46.02 56.05 percent of total billed charges CREATININE; BLOOD 3018256501_1 CDM 301 RC 82565 HCPCS outpatient 59 44.25 AETNA MCR ADV AETNA MCR ADV 46.02 78 999999999 46.02 56.05 percent of total billed charges CREATININE; BLOOD 3018256501_1 CDM 301 RC 82565 HCPCS outpatient 59 44.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 51.67 87.57 999999999 46.02 56.05 percent of total billed charges CREATININE; BLOOD 3018256501_1 CDM 301 RC 82565 HCPCS outpatient 59 44.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 50.19 85.07 999999999 46.02 56.05 percent of total billed charges CREATININE; BLOOD 3018256501_1 CDM 301 RC 82565 HCPCS outpatient 59 44.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50.19 85.07 999999999 46.02 56.05 percent of total billed charges CREATININE; BLOOD 3018256501_1 CDM 301 RC 82565 HCPCS outpatient 59 44.25 MOLINA MCAID MOLINA MCAID 49.21 83.4 999999999 46.02 56.05 percent of total billed charges CREATININE; BLOOD 3018256501_1 CDM 301 RC 82565 HCPCS outpatient 59 44.25 MOLINA MCR ADV MOLINA MCR ADV 52.51 89 999999999 46.02 56.05 percent of total billed charges CREATININE; BLOOD 3018256501_1 CDM 301 RC 82565 HCPCS outpatient 59 44.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 52.51 89 999999999 46.02 56.05 percent of total billed charges CREATININE; BLOOD 3018256501_1 CDM 301 RC 82565 HCPCS outpatient 59 44.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 52.51 89 999999999 46.02 56.05 percent of total billed charges CREATININE; BLOOD 3018256501_1 CDM 301 RC 82565 HCPCS outpatient 59 44.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 53.1 90 999999999 46.02 56.05 percent of total billed charges CREATININE; BLOOD 3018256501_1 CDM 301 RC 82565 HCPCS outpatient 59 44.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 56.05 95 999999999 46.02 56.05 percent of total billed charges CREATININE; BLOOD 3018256501_1 CDM 301 RC 82565 HCPCS outpatient 59 44.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 56.05 95 999999999 46.02 56.05 percent of total billed charges CREATININE; BLOOD 3018256501_1 CDM 301 RC 82565 HCPCS outpatient 59 44.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 52.51 89 999999999 46.02 56.05 percent of total billed charges CREATININE; BLOOD 3018256501_1 CDM 301 RC 82565 HCPCS outpatient 59 44.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 51.92 88 999999999 46.02 56.05 percent of total billed charges CREATININE; BLOOD 3018256501_1 CDM 301 RC 82565 HCPCS outpatient 59 44.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 52.51 89 999999999 46.02 56.05 percent of total billed charges CREATININE; OTHER SOURCE 3018257001_1 CDM 301 RC 82570 HCPCS outpatient 76 57 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 68.4 90 999999999 59.28 72.2 percent of total billed charges CREATININE; OTHER SOURCE 3018257001_1 CDM 301 RC 82570 HCPCS outpatient 76 57 AETNA MCR ADV AETNA MCR ADV 59.28 78 999999999 59.28 72.2 percent of total billed charges CREATININE; OTHER SOURCE 3018257001_1 CDM 301 RC 82570 HCPCS outpatient 76 57 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 66.55 87.57 999999999 59.28 72.2 percent of total billed charges CREATININE; OTHER SOURCE 3018257001_1 CDM 301 RC 82570 HCPCS outpatient 76 57 COORDINATED CARE MCAID COORDINATED CARE MCAID 64.65 85.07 999999999 59.28 72.2 percent of total billed charges CREATININE; OTHER SOURCE 3018257001_1 CDM 301 RC 82570 HCPCS outpatient 76 57 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 64.65 85.07 999999999 59.28 72.2 percent of total billed charges CREATININE; OTHER SOURCE 3018257001_1 CDM 301 RC 82570 HCPCS outpatient 76 57 MOLINA MCAID MOLINA MCAID 63.38 83.4 999999999 59.28 72.2 percent of total billed charges CREATININE; OTHER SOURCE 3018257001_1 CDM 301 RC 82570 HCPCS outpatient 76 57 MOLINA MCR ADV MOLINA MCR ADV 67.64 89 999999999 59.28 72.2 percent of total billed charges CREATININE; OTHER SOURCE 3018257001_1 CDM 301 RC 82570 HCPCS outpatient 76 57 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 67.64 89 999999999 59.28 72.2 percent of total billed charges CREATININE; OTHER SOURCE 3018257001_1 CDM 301 RC 82570 HCPCS outpatient 76 57 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 67.64 89 999999999 59.28 72.2 percent of total billed charges CREATININE; OTHER SOURCE 3018257001_1 CDM 301 RC 82570 HCPCS outpatient 76 57 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 68.4 90 999999999 59.28 72.2 percent of total billed charges CREATININE; OTHER SOURCE 3018257001_1 CDM 301 RC 82570 HCPCS outpatient 76 57 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 72.2 95 999999999 59.28 72.2 percent of total billed charges CREATININE; OTHER SOURCE 3018257001_1 CDM 301 RC 82570 HCPCS outpatient 76 57 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 72.2 95 999999999 59.28 72.2 percent of total billed charges CREATININE; OTHER SOURCE 3018257001_1 CDM 301 RC 82570 HCPCS outpatient 76 57 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 67.64 89 999999999 59.28 72.2 percent of total billed charges CREATININE; OTHER SOURCE 3018257001_1 CDM 301 RC 82570 HCPCS outpatient 76 57 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 66.88 88 999999999 59.28 72.2 percent of total billed charges CREATININE; OTHER SOURCE 3018257001_1 CDM 301 RC 82570 HCPCS outpatient 76 57 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 67.64 89 999999999 59.28 72.2 percent of total billed charges CREATININE; CLEARANCE 3018257501_1 CDM 301 RC 82575 HCPCS outpatient 104 78 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 93.6 90 999999999 81.12 98.8 percent of total billed charges CREATININE; CLEARANCE 3018257501_1 CDM 301 RC 82575 HCPCS outpatient 104 78 AETNA MCR ADV AETNA MCR ADV 81.12 78 999999999 81.12 98.8 percent of total billed charges CREATININE; CLEARANCE 3018257501_1 CDM 301 RC 82575 HCPCS outpatient 104 78 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 91.07 87.57 999999999 81.12 98.8 percent of total billed charges CREATININE; CLEARANCE 3018257501_1 CDM 301 RC 82575 HCPCS outpatient 104 78 COORDINATED CARE MCAID COORDINATED CARE MCAID 88.47 85.07 999999999 81.12 98.8 percent of total billed charges CREATININE; CLEARANCE 3018257501_1 CDM 301 RC 82575 HCPCS outpatient 104 78 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 88.47 85.07 999999999 81.12 98.8 percent of total billed charges CREATININE; CLEARANCE 3018257501_1 CDM 301 RC 82575 HCPCS outpatient 104 78 MOLINA MCAID MOLINA MCAID 86.74 83.4 999999999 81.12 98.8 percent of total billed charges CREATININE; CLEARANCE 3018257501_1 CDM 301 RC 82575 HCPCS outpatient 104 78 MOLINA MCR ADV MOLINA MCR ADV 92.56 89 999999999 81.12 98.8 percent of total billed charges CREATININE; CLEARANCE 3018257501_1 CDM 301 RC 82575 HCPCS outpatient 104 78 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 92.56 89 999999999 81.12 98.8 percent of total billed charges CREATININE; CLEARANCE 3018257501_1 CDM 301 RC 82575 HCPCS outpatient 104 78 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 92.56 89 999999999 81.12 98.8 percent of total billed charges CREATININE; CLEARANCE 3018257501_1 CDM 301 RC 82575 HCPCS outpatient 104 78 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 93.6 90 999999999 81.12 98.8 percent of total billed charges CREATININE; CLEARANCE 3018257501_1 CDM 301 RC 82575 HCPCS outpatient 104 78 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 98.8 95 999999999 81.12 98.8 percent of total billed charges CREATININE; CLEARANCE 3018257501_1 CDM 301 RC 82575 HCPCS outpatient 104 78 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 98.8 95 999999999 81.12 98.8 percent of total billed charges CREATININE; CLEARANCE 3018257501_1 CDM 301 RC 82575 HCPCS outpatient 104 78 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 92.56 89 999999999 81.12 98.8 percent of total billed charges CREATININE; CLEARANCE 3018257501_1 CDM 301 RC 82575 HCPCS outpatient 104 78 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 91.52 88 999999999 81.12 98.8 percent of total billed charges CREATININE; CLEARANCE 3018257501_1 CDM 301 RC 82575 HCPCS outpatient 104 78 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 92.56 89 999999999 81.12 98.8 percent of total billed charges CYANOCOBALAMIN (VITAMIN B-12) 3018260701_1 CDM 301 RC 82607 HCPCS outpatient 112 84 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 100.8 90 999999999 87.36 106.4 percent of total billed charges CYANOCOBALAMIN (VITAMIN B-12) 3018260701_1 CDM 301 RC 82607 HCPCS outpatient 112 84 AETNA MCR ADV AETNA MCR ADV 87.36 78 999999999 87.36 106.4 percent of total billed charges CYANOCOBALAMIN (VITAMIN B-12) 3018260701_1 CDM 301 RC 82607 HCPCS outpatient 112 84 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 98.08 87.57 999999999 87.36 106.4 percent of total billed charges CYANOCOBALAMIN (VITAMIN B-12) 3018260701_1 CDM 301 RC 82607 HCPCS outpatient 112 84 COORDINATED CARE MCAID COORDINATED CARE MCAID 95.28 85.07 999999999 87.36 106.4 percent of total billed charges CYANOCOBALAMIN (VITAMIN B-12) 3018260701_1 CDM 301 RC 82607 HCPCS outpatient 112 84 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 95.28 85.07 999999999 87.36 106.4 percent of total billed charges CYANOCOBALAMIN (VITAMIN B-12) 3018260701_1 CDM 301 RC 82607 HCPCS outpatient 112 84 MOLINA MCAID MOLINA MCAID 93.41 83.4 999999999 87.36 106.4 percent of total billed charges CYANOCOBALAMIN (VITAMIN B-12) 3018260701_1 CDM 301 RC 82607 HCPCS outpatient 112 84 MOLINA MCR ADV MOLINA MCR ADV 99.68 89 999999999 87.36 106.4 percent of total billed charges CYANOCOBALAMIN (VITAMIN B-12) 3018260701_1 CDM 301 RC 82607 HCPCS outpatient 112 84 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 99.68 89 999999999 87.36 106.4 percent of total billed charges CYANOCOBALAMIN (VITAMIN B-12) 3018260701_1 CDM 301 RC 82607 HCPCS outpatient 112 84 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 99.68 89 999999999 87.36 106.4 percent of total billed charges CYANOCOBALAMIN (VITAMIN B-12) 3018260701_1 CDM 301 RC 82607 HCPCS outpatient 112 84 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 100.8 90 999999999 87.36 106.4 percent of total billed charges CYANOCOBALAMIN (VITAMIN B-12) 3018260701_1 CDM 301 RC 82607 HCPCS outpatient 112 84 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 106.4 95 999999999 87.36 106.4 percent of total billed charges CYANOCOBALAMIN (VITAMIN B-12) 3018260701_1 CDM 301 RC 82607 HCPCS outpatient 112 84 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 106.4 95 999999999 87.36 106.4 percent of total billed charges CYANOCOBALAMIN (VITAMIN B-12) 3018260701_1 CDM 301 RC 82607 HCPCS outpatient 112 84 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 99.68 89 999999999 87.36 106.4 percent of total billed charges CYANOCOBALAMIN (VITAMIN B-12) 3018260701_1 CDM 301 RC 82607 HCPCS outpatient 112 84 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 98.56 88 999999999 87.36 106.4 percent of total billed charges CYANOCOBALAMIN (VITAMIN B-12) 3018260701_1 CDM 301 RC 82607 HCPCS outpatient 112 84 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 99.68 89 999999999 87.36 106.4 percent of total billed charges DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S) 3018262701_1 CDM 301 RC 82627 HCPCS outpatient 104 78 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 93.6 90 999999999 81.12 98.8 percent of total billed charges DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S) 3018262701_1 CDM 301 RC 82627 HCPCS outpatient 104 78 AETNA MCR ADV AETNA MCR ADV 81.12 78 999999999 81.12 98.8 percent of total billed charges DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S) 3018262701_1 CDM 301 RC 82627 HCPCS outpatient 104 78 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 91.07 87.57 999999999 81.12 98.8 percent of total billed charges DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S) 3018262701_1 CDM 301 RC 82627 HCPCS outpatient 104 78 COORDINATED CARE MCAID COORDINATED CARE MCAID 88.47 85.07 999999999 81.12 98.8 percent of total billed charges DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S) 3018262701_1 CDM 301 RC 82627 HCPCS outpatient 104 78 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 88.47 85.07 999999999 81.12 98.8 percent of total billed charges DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S) 3018262701_1 CDM 301 RC 82627 HCPCS outpatient 104 78 MOLINA MCAID MOLINA MCAID 86.74 83.4 999999999 81.12 98.8 percent of total billed charges DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S) 3018262701_1 CDM 301 RC 82627 HCPCS outpatient 104 78 MOLINA MCR ADV MOLINA MCR ADV 92.56 89 999999999 81.12 98.8 percent of total billed charges DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S) 3018262701_1 CDM 301 RC 82627 HCPCS outpatient 104 78 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 92.56 89 999999999 81.12 98.8 percent of total billed charges DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S) 3018262701_1 CDM 301 RC 82627 HCPCS outpatient 104 78 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 92.56 89 999999999 81.12 98.8 percent of total billed charges DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S) 3018262701_1 CDM 301 RC 82627 HCPCS outpatient 104 78 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 93.6 90 999999999 81.12 98.8 percent of total billed charges DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S) 3018262701_1 CDM 301 RC 82627 HCPCS outpatient 104 78 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 98.8 95 999999999 81.12 98.8 percent of total billed charges DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S) 3018262701_1 CDM 301 RC 82627 HCPCS outpatient 104 78 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 98.8 95 999999999 81.12 98.8 percent of total billed charges DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S) 3018262701_1 CDM 301 RC 82627 HCPCS outpatient 104 78 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 92.56 89 999999999 81.12 98.8 percent of total billed charges DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S) 3018262701_1 CDM 301 RC 82627 HCPCS outpatient 104 78 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 91.52 88 999999999 81.12 98.8 percent of total billed charges DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S) 3018262701_1 CDM 301 RC 82627 HCPCS outpatient 104 78 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 92.56 89 999999999 81.12 98.8 percent of total billed charges "VITAMIN D; 1, 25 DIHYDROXY, INCLUDES FRACTION(S), IF PERFORMED" 3018265202_1 CDM 301 RC 82652 HCPCS outpatient 172 129 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 154.8 90 999999999 134.16 163.4 percent of total billed charges "VITAMIN D; 1, 25 DIHYDROXY, INCLUDES FRACTION(S), IF PERFORMED" 3018265202_1 CDM 301 RC 82652 HCPCS outpatient 172 129 AETNA MCR ADV AETNA MCR ADV 134.16 78 999999999 134.16 163.4 percent of total billed charges "VITAMIN D; 1, 25 DIHYDROXY, INCLUDES FRACTION(S), IF PERFORMED" 3018265202_1 CDM 301 RC 82652 HCPCS outpatient 172 129 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 150.62 87.57 999999999 134.16 163.4 percent of total billed charges "VITAMIN D; 1, 25 DIHYDROXY, INCLUDES FRACTION(S), IF PERFORMED" 3018265202_1 CDM 301 RC 82652 HCPCS outpatient 172 129 COORDINATED CARE MCAID COORDINATED CARE MCAID 146.32 85.07 999999999 134.16 163.4 percent of total billed charges "VITAMIN D; 1, 25 DIHYDROXY, INCLUDES FRACTION(S), IF PERFORMED" 3018265202_1 CDM 301 RC 82652 HCPCS outpatient 172 129 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 146.32 85.07 999999999 134.16 163.4 percent of total billed charges "VITAMIN D; 1, 25 DIHYDROXY, INCLUDES FRACTION(S), IF PERFORMED" 3018265202_1 CDM 301 RC 82652 HCPCS outpatient 172 129 MOLINA MCAID MOLINA MCAID 143.45 83.4 999999999 134.16 163.4 percent of total billed charges "VITAMIN D; 1, 25 DIHYDROXY, INCLUDES FRACTION(S), IF PERFORMED" 3018265202_1 CDM 301 RC 82652 HCPCS outpatient 172 129 MOLINA MCR ADV MOLINA MCR ADV 153.08 89 999999999 134.16 163.4 percent of total billed charges "VITAMIN D; 1, 25 DIHYDROXY, INCLUDES FRACTION(S), IF PERFORMED" 3018265202_1 CDM 301 RC 82652 HCPCS outpatient 172 129 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 153.08 89 999999999 134.16 163.4 percent of total billed charges "VITAMIN D; 1, 25 DIHYDROXY, INCLUDES FRACTION(S), IF PERFORMED" 3018265202_1 CDM 301 RC 82652 HCPCS outpatient 172 129 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 153.08 89 999999999 134.16 163.4 percent of total billed charges "VITAMIN D; 1, 25 DIHYDROXY, INCLUDES FRACTION(S), IF PERFORMED" 3018265202_1 CDM 301 RC 82652 HCPCS outpatient 172 129 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 154.8 90 999999999 134.16 163.4 percent of total billed charges "VITAMIN D; 1, 25 DIHYDROXY, INCLUDES FRACTION(S), IF PERFORMED" 3018265202_1 CDM 301 RC 82652 HCPCS outpatient 172 129 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 163.4 95 999999999 134.16 163.4 percent of total billed charges "VITAMIN D; 1, 25 DIHYDROXY, INCLUDES FRACTION(S), IF PERFORMED" 3018265202_1 CDM 301 RC 82652 HCPCS outpatient 172 129 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 163.4 95 999999999 134.16 163.4 percent of total billed charges "VITAMIN D; 1, 25 DIHYDROXY, INCLUDES FRACTION(S), IF PERFORMED" 3018265202_1 CDM 301 RC 82652 HCPCS outpatient 172 129 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 153.08 89 999999999 134.16 163.4 percent of total billed charges "VITAMIN D; 1, 25 DIHYDROXY, INCLUDES FRACTION(S), IF PERFORMED" 3018265202_1 CDM 301 RC 82652 HCPCS outpatient 172 129 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 151.36 88 999999999 134.16 163.4 percent of total billed charges "VITAMIN D; 1, 25 DIHYDROXY, INCLUDES FRACTION(S), IF PERFORMED" 3018265202_1 CDM 301 RC 82652 HCPCS outpatient 172 129 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 153.08 89 999999999 134.16 163.4 percent of total billed charges ESTRADIOL; TOTAL 3018267001_1 CDM 301 RC 82670 HCPCS outpatient 145 108.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 130.5 90 999999999 113.1 137.75 percent of total billed charges ESTRADIOL; TOTAL 3018267001_1 CDM 301 RC 82670 HCPCS outpatient 145 108.75 AETNA MCR ADV AETNA MCR ADV 113.1 78 999999999 113.1 137.75 percent of total billed charges ESTRADIOL; TOTAL 3018267001_1 CDM 301 RC 82670 HCPCS outpatient 145 108.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 126.98 87.57 999999999 113.1 137.75 percent of total billed charges ESTRADIOL; TOTAL 3018267001_1 CDM 301 RC 82670 HCPCS outpatient 145 108.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 123.35 85.07 999999999 113.1 137.75 percent of total billed charges ESTRADIOL; TOTAL 3018267001_1 CDM 301 RC 82670 HCPCS outpatient 145 108.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 123.35 85.07 999999999 113.1 137.75 percent of total billed charges ESTRADIOL; TOTAL 3018267001_1 CDM 301 RC 82670 HCPCS outpatient 145 108.75 MOLINA MCAID MOLINA MCAID 120.93 83.4 999999999 113.1 137.75 percent of total billed charges ESTRADIOL; TOTAL 3018267001_1 CDM 301 RC 82670 HCPCS outpatient 145 108.75 MOLINA MCR ADV MOLINA MCR ADV 129.05 89 999999999 113.1 137.75 percent of total billed charges ESTRADIOL; TOTAL 3018267001_1 CDM 301 RC 82670 HCPCS outpatient 145 108.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 129.05 89 999999999 113.1 137.75 percent of total billed charges ESTRADIOL; TOTAL 3018267001_1 CDM 301 RC 82670 HCPCS outpatient 145 108.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 129.05 89 999999999 113.1 137.75 percent of total billed charges ESTRADIOL; TOTAL 3018267001_1 CDM 301 RC 82670 HCPCS outpatient 145 108.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 130.5 90 999999999 113.1 137.75 percent of total billed charges ESTRADIOL; TOTAL 3018267001_1 CDM 301 RC 82670 HCPCS outpatient 145 108.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 137.75 95 999999999 113.1 137.75 percent of total billed charges ESTRADIOL; TOTAL 3018267001_1 CDM 301 RC 82670 HCPCS outpatient 145 108.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 137.75 95 999999999 113.1 137.75 percent of total billed charges ESTRADIOL; TOTAL 3018267001_1 CDM 301 RC 82670 HCPCS outpatient 145 108.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 129.05 89 999999999 113.1 137.75 percent of total billed charges ESTRADIOL; TOTAL 3018267001_1 CDM 301 RC 82670 HCPCS outpatient 145 108.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 127.6 88 999999999 113.1 137.75 percent of total billed charges ESTRADIOL; TOTAL 3018267001_1 CDM 301 RC 82670 HCPCS outpatient 145 108.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 129.05 89 999999999 113.1 137.75 percent of total billed charges ESTRONE 3018267902_1 CDM 301 RC 82679 HCPCS outpatient 211 158.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 189.9 90 999999999 164.58 200.45 percent of total billed charges ESTRONE 3018267902_1 CDM 301 RC 82679 HCPCS outpatient 211 158.25 AETNA MCR ADV AETNA MCR ADV 164.58 78 999999999 164.58 200.45 percent of total billed charges ESTRONE 3018267902_1 CDM 301 RC 82679 HCPCS outpatient 211 158.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 184.77 87.57 999999999 164.58 200.45 percent of total billed charges ESTRONE 3018267902_1 CDM 301 RC 82679 HCPCS outpatient 211 158.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 179.5 85.07 999999999 164.58 200.45 percent of total billed charges ESTRONE 3018267902_1 CDM 301 RC 82679 HCPCS outpatient 211 158.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 179.5 85.07 999999999 164.58 200.45 percent of total billed charges ESTRONE 3018267902_1 CDM 301 RC 82679 HCPCS outpatient 211 158.25 MOLINA MCAID MOLINA MCAID 175.97 83.4 999999999 164.58 200.45 percent of total billed charges ESTRONE 3018267902_1 CDM 301 RC 82679 HCPCS outpatient 211 158.25 MOLINA MCR ADV MOLINA MCR ADV 187.79 89 999999999 164.58 200.45 percent of total billed charges ESTRONE 3018267902_1 CDM 301 RC 82679 HCPCS outpatient 211 158.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 187.79 89 999999999 164.58 200.45 percent of total billed charges ESTRONE 3018267902_1 CDM 301 RC 82679 HCPCS outpatient 211 158.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 187.79 89 999999999 164.58 200.45 percent of total billed charges ESTRONE 3018267902_1 CDM 301 RC 82679 HCPCS outpatient 211 158.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 189.9 90 999999999 164.58 200.45 percent of total billed charges ESTRONE 3018267902_1 CDM 301 RC 82679 HCPCS outpatient 211 158.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 200.45 95 999999999 164.58 200.45 percent of total billed charges ESTRONE 3018267902_1 CDM 301 RC 82679 HCPCS outpatient 211 158.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 200.45 95 999999999 164.58 200.45 percent of total billed charges ESTRONE 3018267902_1 CDM 301 RC 82679 HCPCS outpatient 211 158.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 187.79 89 999999999 164.58 200.45 percent of total billed charges ESTRONE 3018267902_1 CDM 301 RC 82679 HCPCS outpatient 211 158.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 185.68 88 999999999 164.58 200.45 percent of total billed charges ESTRONE 3018267902_1 CDM 301 RC 82679 HCPCS outpatient 211 158.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 187.79 89 999999999 164.58 200.45 percent of total billed charges "FAT OR LIPIDS, FECES; QUALITATIVE" 3018270501_1 CDM 301 RC 82705 HCPCS outpatient 151 113.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 135.9 90 999999999 117.78 143.45 percent of total billed charges "FAT OR LIPIDS, FECES; QUALITATIVE" 3018270501_1 CDM 301 RC 82705 HCPCS outpatient 151 113.25 AETNA MCR ADV AETNA MCR ADV 117.78 78 999999999 117.78 143.45 percent of total billed charges "FAT OR LIPIDS, FECES; QUALITATIVE" 3018270501_1 CDM 301 RC 82705 HCPCS outpatient 151 113.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 132.23 87.57 999999999 117.78 143.45 percent of total billed charges "FAT OR LIPIDS, FECES; QUALITATIVE" 3018270501_1 CDM 301 RC 82705 HCPCS outpatient 151 113.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 128.46 85.07 999999999 117.78 143.45 percent of total billed charges "FAT OR LIPIDS, FECES; QUALITATIVE" 3018270501_1 CDM 301 RC 82705 HCPCS outpatient 151 113.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 128.46 85.07 999999999 117.78 143.45 percent of total billed charges "FAT OR LIPIDS, FECES; QUALITATIVE" 3018270501_1 CDM 301 RC 82705 HCPCS outpatient 151 113.25 MOLINA MCAID MOLINA MCAID 125.93 83.4 999999999 117.78 143.45 percent of total billed charges "FAT OR LIPIDS, FECES; QUALITATIVE" 3018270501_1 CDM 301 RC 82705 HCPCS outpatient 151 113.25 MOLINA MCR ADV MOLINA MCR ADV 134.39 89 999999999 117.78 143.45 percent of total billed charges "FAT OR LIPIDS, FECES; QUALITATIVE" 3018270501_1 CDM 301 RC 82705 HCPCS outpatient 151 113.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 134.39 89 999999999 117.78 143.45 percent of total billed charges "FAT OR LIPIDS, FECES; QUALITATIVE" 3018270501_1 CDM 301 RC 82705 HCPCS outpatient 151 113.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 134.39 89 999999999 117.78 143.45 percent of total billed charges "FAT OR LIPIDS, FECES; QUALITATIVE" 3018270501_1 CDM 301 RC 82705 HCPCS outpatient 151 113.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 135.9 90 999999999 117.78 143.45 percent of total billed charges "FAT OR LIPIDS, FECES; QUALITATIVE" 3018270501_1 CDM 301 RC 82705 HCPCS outpatient 151 113.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 143.45 95 999999999 117.78 143.45 percent of total billed charges "FAT OR LIPIDS, FECES; QUALITATIVE" 3018270501_1 CDM 301 RC 82705 HCPCS outpatient 151 113.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 143.45 95 999999999 117.78 143.45 percent of total billed charges "FAT OR LIPIDS, FECES; QUALITATIVE" 3018270501_1 CDM 301 RC 82705 HCPCS outpatient 151 113.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 134.39 89 999999999 117.78 143.45 percent of total billed charges "FAT OR LIPIDS, FECES; QUALITATIVE" 3018270501_1 CDM 301 RC 82705 HCPCS outpatient 151 113.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 132.88 88 999999999 117.78 143.45 percent of total billed charges "FAT OR LIPIDS, FECES; QUALITATIVE" 3018270501_1 CDM 301 RC 82705 HCPCS outpatient 151 113.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 134.39 89 999999999 117.78 143.45 percent of total billed charges FERRITIN 3018272801_1 CDM 301 RC 82728 HCPCS outpatient 127 95.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 114.3 90 999999999 99.06 120.65 percent of total billed charges FERRITIN 3018272801_1 CDM 301 RC 82728 HCPCS outpatient 127 95.25 AETNA MCR ADV AETNA MCR ADV 99.06 78 999999999 99.06 120.65 percent of total billed charges FERRITIN 3018272801_1 CDM 301 RC 82728 HCPCS outpatient 127 95.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 111.21 87.57 999999999 99.06 120.65 percent of total billed charges FERRITIN 3018272801_1 CDM 301 RC 82728 HCPCS outpatient 127 95.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 108.04 85.07 999999999 99.06 120.65 percent of total billed charges FERRITIN 3018272801_1 CDM 301 RC 82728 HCPCS outpatient 127 95.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 108.04 85.07 999999999 99.06 120.65 percent of total billed charges FERRITIN 3018272801_1 CDM 301 RC 82728 HCPCS outpatient 127 95.25 MOLINA MCAID MOLINA MCAID 105.92 83.4 999999999 99.06 120.65 percent of total billed charges FERRITIN 3018272801_1 CDM 301 RC 82728 HCPCS outpatient 127 95.25 MOLINA MCR ADV MOLINA MCR ADV 113.03 89 999999999 99.06 120.65 percent of total billed charges FERRITIN 3018272801_1 CDM 301 RC 82728 HCPCS outpatient 127 95.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 113.03 89 999999999 99.06 120.65 percent of total billed charges FERRITIN 3018272801_1 CDM 301 RC 82728 HCPCS outpatient 127 95.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 113.03 89 999999999 99.06 120.65 percent of total billed charges FERRITIN 3018272801_1 CDM 301 RC 82728 HCPCS outpatient 127 95.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 114.3 90 999999999 99.06 120.65 percent of total billed charges FERRITIN 3018272801_1 CDM 301 RC 82728 HCPCS outpatient 127 95.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 120.65 95 999999999 99.06 120.65 percent of total billed charges FERRITIN 3018272801_1 CDM 301 RC 82728 HCPCS outpatient 127 95.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 120.65 95 999999999 99.06 120.65 percent of total billed charges FERRITIN 3018272801_1 CDM 301 RC 82728 HCPCS outpatient 127 95.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 113.03 89 999999999 99.06 120.65 percent of total billed charges FERRITIN 3018272801_1 CDM 301 RC 82728 HCPCS outpatient 127 95.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 111.76 88 999999999 99.06 120.65 percent of total billed charges FERRITIN 3018272801_1 CDM 301 RC 82728 HCPCS outpatient 127 95.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 113.03 89 999999999 99.06 120.65 percent of total billed charges FOLIC ACID; SERUM 3018274601_1 CDM 301 RC 82746 HCPCS outpatient 94 70.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 84.6 90 999999999 73.32 89.3 percent of total billed charges FOLIC ACID; SERUM 3018274601_1 CDM 301 RC 82746 HCPCS outpatient 94 70.5 AETNA MCR ADV AETNA MCR ADV 73.32 78 999999999 73.32 89.3 percent of total billed charges FOLIC ACID; SERUM 3018274601_1 CDM 301 RC 82746 HCPCS outpatient 94 70.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 82.32 87.57 999999999 73.32 89.3 percent of total billed charges FOLIC ACID; SERUM 3018274601_1 CDM 301 RC 82746 HCPCS outpatient 94 70.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 79.97 85.07 999999999 73.32 89.3 percent of total billed charges FOLIC ACID; SERUM 3018274601_1 CDM 301 RC 82746 HCPCS outpatient 94 70.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 79.97 85.07 999999999 73.32 89.3 percent of total billed charges FOLIC ACID; SERUM 3018274601_1 CDM 301 RC 82746 HCPCS outpatient 94 70.5 MOLINA MCAID MOLINA MCAID 78.4 83.4 999999999 73.32 89.3 percent of total billed charges FOLIC ACID; SERUM 3018274601_1 CDM 301 RC 82746 HCPCS outpatient 94 70.5 MOLINA MCR ADV MOLINA MCR ADV 83.66 89 999999999 73.32 89.3 percent of total billed charges FOLIC ACID; SERUM 3018274601_1 CDM 301 RC 82746 HCPCS outpatient 94 70.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 83.66 89 999999999 73.32 89.3 percent of total billed charges FOLIC ACID; SERUM 3018274601_1 CDM 301 RC 82746 HCPCS outpatient 94 70.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 83.66 89 999999999 73.32 89.3 percent of total billed charges FOLIC ACID; SERUM 3018274601_1 CDM 301 RC 82746 HCPCS outpatient 94 70.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 84.6 90 999999999 73.32 89.3 percent of total billed charges FOLIC ACID; SERUM 3018274601_1 CDM 301 RC 82746 HCPCS outpatient 94 70.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 89.3 95 999999999 73.32 89.3 percent of total billed charges FOLIC ACID; SERUM 3018274601_1 CDM 301 RC 82746 HCPCS outpatient 94 70.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 89.3 95 999999999 73.32 89.3 percent of total billed charges FOLIC ACID; SERUM 3018274601_1 CDM 301 RC 82746 HCPCS outpatient 94 70.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 83.66 89 999999999 73.32 89.3 percent of total billed charges FOLIC ACID; SERUM 3018274601_1 CDM 301 RC 82746 HCPCS outpatient 94 70.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 82.72 88 999999999 73.32 89.3 percent of total billed charges FOLIC ACID; SERUM 3018274601_1 CDM 301 RC 82746 HCPCS outpatient 94 70.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 83.66 89 999999999 73.32 89.3 percent of total billed charges "GAMMAGLOBULIN (IMMUNOGLOBULIN); IGA, IGD, IGG, IGM, EACH" 3018278410_1 CDM 301 RC 82784 HCPCS outpatient 96 72 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 86.4 90 999999999 74.88 91.2 percent of total billed charges "GAMMAGLOBULIN (IMMUNOGLOBULIN); IGA, IGD, IGG, IGM, EACH" 3018278410_1 CDM 301 RC 82784 HCPCS outpatient 96 72 AETNA MCR ADV AETNA MCR ADV 74.88 78 999999999 74.88 91.2 percent of total billed charges "GAMMAGLOBULIN (IMMUNOGLOBULIN); IGA, IGD, IGG, IGM, EACH" 3018278410_1 CDM 301 RC 82784 HCPCS outpatient 96 72 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 84.07 87.57 999999999 74.88 91.2 percent of total billed charges "GAMMAGLOBULIN (IMMUNOGLOBULIN); IGA, IGD, IGG, IGM, EACH" 3018278410_1 CDM 301 RC 82784 HCPCS outpatient 96 72 COORDINATED CARE MCAID COORDINATED CARE MCAID 81.67 85.07 999999999 74.88 91.2 percent of total billed charges "GAMMAGLOBULIN (IMMUNOGLOBULIN); IGA, IGD, IGG, IGM, EACH" 3018278410_1 CDM 301 RC 82784 HCPCS outpatient 96 72 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 81.67 85.07 999999999 74.88 91.2 percent of total billed charges "GAMMAGLOBULIN (IMMUNOGLOBULIN); IGA, IGD, IGG, IGM, EACH" 3018278410_1 CDM 301 RC 82784 HCPCS outpatient 96 72 MOLINA MCAID MOLINA MCAID 80.06 83.4 999999999 74.88 91.2 percent of total billed charges "GAMMAGLOBULIN (IMMUNOGLOBULIN); IGA, IGD, IGG, IGM, EACH" 3018278410_1 CDM 301 RC 82784 HCPCS outpatient 96 72 MOLINA MCR ADV MOLINA MCR ADV 85.44 89 999999999 74.88 91.2 percent of total billed charges "GAMMAGLOBULIN (IMMUNOGLOBULIN); IGA, IGD, IGG, IGM, EACH" 3018278410_1 CDM 301 RC 82784 HCPCS outpatient 96 72 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 85.44 89 999999999 74.88 91.2 percent of total billed charges "GAMMAGLOBULIN (IMMUNOGLOBULIN); IGA, IGD, IGG, IGM, EACH" 3018278410_1 CDM 301 RC 82784 HCPCS outpatient 96 72 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 85.44 89 999999999 74.88 91.2 percent of total billed charges "GAMMAGLOBULIN (IMMUNOGLOBULIN); IGA, IGD, IGG, IGM, EACH" 3018278410_1 CDM 301 RC 82784 HCPCS outpatient 96 72 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 86.4 90 999999999 74.88 91.2 percent of total billed charges "GAMMAGLOBULIN (IMMUNOGLOBULIN); IGA, IGD, IGG, IGM, EACH" 3018278410_1 CDM 301 RC 82784 HCPCS outpatient 96 72 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 91.2 95 999999999 74.88 91.2 percent of total billed charges "GAMMAGLOBULIN (IMMUNOGLOBULIN); IGA, IGD, IGG, IGM, EACH" 3018278410_1 CDM 301 RC 82784 HCPCS outpatient 96 72 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 91.2 95 999999999 74.88 91.2 percent of total billed charges "GAMMAGLOBULIN (IMMUNOGLOBULIN); IGA, IGD, IGG, IGM, EACH" 3018278410_1 CDM 301 RC 82784 HCPCS outpatient 96 72 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 85.44 89 999999999 74.88 91.2 percent of total billed charges "GAMMAGLOBULIN (IMMUNOGLOBULIN); IGA, IGD, IGG, IGM, EACH" 3018278410_1 CDM 301 RC 82784 HCPCS outpatient 96 72 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 84.48 88 999999999 74.88 91.2 percent of total billed charges "GAMMAGLOBULIN (IMMUNOGLOBULIN); IGA, IGD, IGG, IGM, EACH" 3018278410_1 CDM 301 RC 82784 HCPCS outpatient 96 72 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 85.44 89 999999999 74.88 91.2 percent of total billed charges GAMMAGLOBULIN (IMMUNOGLOBULIN); IGE 3018278502_1 CDM 301 RC 82785 HCPCS outpatient 104 78 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 93.6 90 999999999 81.12 98.8 percent of total billed charges GAMMAGLOBULIN (IMMUNOGLOBULIN); IGE 3018278502_1 CDM 301 RC 82785 HCPCS outpatient 104 78 AETNA MCR ADV AETNA MCR ADV 81.12 78 999999999 81.12 98.8 percent of total billed charges GAMMAGLOBULIN (IMMUNOGLOBULIN); IGE 3018278502_1 CDM 301 RC 82785 HCPCS outpatient 104 78 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 91.07 87.57 999999999 81.12 98.8 percent of total billed charges GAMMAGLOBULIN (IMMUNOGLOBULIN); IGE 3018278502_1 CDM 301 RC 82785 HCPCS outpatient 104 78 COORDINATED CARE MCAID COORDINATED CARE MCAID 88.47 85.07 999999999 81.12 98.8 percent of total billed charges GAMMAGLOBULIN (IMMUNOGLOBULIN); IGE 3018278502_1 CDM 301 RC 82785 HCPCS outpatient 104 78 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 88.47 85.07 999999999 81.12 98.8 percent of total billed charges GAMMAGLOBULIN (IMMUNOGLOBULIN); IGE 3018278502_1 CDM 301 RC 82785 HCPCS outpatient 104 78 MOLINA MCAID MOLINA MCAID 86.74 83.4 999999999 81.12 98.8 percent of total billed charges GAMMAGLOBULIN (IMMUNOGLOBULIN); IGE 3018278502_1 CDM 301 RC 82785 HCPCS outpatient 104 78 MOLINA MCR ADV MOLINA MCR ADV 92.56 89 999999999 81.12 98.8 percent of total billed charges GAMMAGLOBULIN (IMMUNOGLOBULIN); IGE 3018278502_1 CDM 301 RC 82785 HCPCS outpatient 104 78 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 92.56 89 999999999 81.12 98.8 percent of total billed charges GAMMAGLOBULIN (IMMUNOGLOBULIN); IGE 3018278502_1 CDM 301 RC 82785 HCPCS outpatient 104 78 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 92.56 89 999999999 81.12 98.8 percent of total billed charges GAMMAGLOBULIN (IMMUNOGLOBULIN); IGE 3018278502_1 CDM 301 RC 82785 HCPCS outpatient 104 78 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 93.6 90 999999999 81.12 98.8 percent of total billed charges GAMMAGLOBULIN (IMMUNOGLOBULIN); IGE 3018278502_1 CDM 301 RC 82785 HCPCS outpatient 104 78 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 98.8 95 999999999 81.12 98.8 percent of total billed charges GAMMAGLOBULIN (IMMUNOGLOBULIN); IGE 3018278502_1 CDM 301 RC 82785 HCPCS outpatient 104 78 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 98.8 95 999999999 81.12 98.8 percent of total billed charges GAMMAGLOBULIN (IMMUNOGLOBULIN); IGE 3018278502_1 CDM 301 RC 82785 HCPCS outpatient 104 78 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 92.56 89 999999999 81.12 98.8 percent of total billed charges GAMMAGLOBULIN (IMMUNOGLOBULIN); IGE 3018278502_1 CDM 301 RC 82785 HCPCS outpatient 104 78 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 91.52 88 999999999 81.12 98.8 percent of total billed charges GAMMAGLOBULIN (IMMUNOGLOBULIN); IGE 3018278502_1 CDM 301 RC 82785 HCPCS outpatient 104 78 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 92.56 89 999999999 81.12 98.8 percent of total billed charges "GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, CO2, HCO3 (INCLUDING CALCULATED O2 SATURATION)" 3018280305_1 CDM 301 RC 82803 HCPCS outpatient 212 159 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 190.8 90 999999999 165.36 201.4 percent of total billed charges "GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, CO2, HCO3 (INCLUDING CALCULATED O2 SATURATION)" 3018280305_1 CDM 301 RC 82803 HCPCS outpatient 212 159 AETNA MCR ADV AETNA MCR ADV 165.36 78 999999999 165.36 201.4 percent of total billed charges "GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, CO2, HCO3 (INCLUDING CALCULATED O2 SATURATION)" 3018280305_1 CDM 301 RC 82803 HCPCS outpatient 212 159 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 185.65 87.57 999999999 165.36 201.4 percent of total billed charges "GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, CO2, HCO3 (INCLUDING CALCULATED O2 SATURATION)" 3018280305_1 CDM 301 RC 82803 HCPCS outpatient 212 159 COORDINATED CARE MCAID COORDINATED CARE MCAID 180.35 85.07 999999999 165.36 201.4 percent of total billed charges "GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, CO2, HCO3 (INCLUDING CALCULATED O2 SATURATION)" 3018280305_1 CDM 301 RC 82803 HCPCS outpatient 212 159 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 180.35 85.07 999999999 165.36 201.4 percent of total billed charges "GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, CO2, HCO3 (INCLUDING CALCULATED O2 SATURATION)" 3018280305_1 CDM 301 RC 82803 HCPCS outpatient 212 159 MOLINA MCAID MOLINA MCAID 176.81 83.4 999999999 165.36 201.4 percent of total billed charges "GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, CO2, HCO3 (INCLUDING CALCULATED O2 SATURATION)" 3018280305_1 CDM 301 RC 82803 HCPCS outpatient 212 159 MOLINA MCR ADV MOLINA MCR ADV 188.68 89 999999999 165.36 201.4 percent of total billed charges "GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, CO2, HCO3 (INCLUDING CALCULATED O2 SATURATION)" 3018280305_1 CDM 301 RC 82803 HCPCS outpatient 212 159 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 188.68 89 999999999 165.36 201.4 percent of total billed charges "GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, CO2, HCO3 (INCLUDING CALCULATED O2 SATURATION)" 3018280305_1 CDM 301 RC 82803 HCPCS outpatient 212 159 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 188.68 89 999999999 165.36 201.4 percent of total billed charges "GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, CO2, HCO3 (INCLUDING CALCULATED O2 SATURATION)" 3018280305_1 CDM 301 RC 82803 HCPCS outpatient 212 159 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 190.8 90 999999999 165.36 201.4 percent of total billed charges "GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, CO2, HCO3 (INCLUDING CALCULATED O2 SATURATION)" 3018280305_1 CDM 301 RC 82803 HCPCS outpatient 212 159 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 201.4 95 999999999 165.36 201.4 percent of total billed charges "GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, CO2, HCO3 (INCLUDING CALCULATED O2 SATURATION)" 3018280305_1 CDM 301 RC 82803 HCPCS outpatient 212 159 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 201.4 95 999999999 165.36 201.4 percent of total billed charges "GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, CO2, HCO3 (INCLUDING CALCULATED O2 SATURATION)" 3018280305_1 CDM 301 RC 82803 HCPCS outpatient 212 159 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 188.68 89 999999999 165.36 201.4 percent of total billed charges "GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, CO2, HCO3 (INCLUDING CALCULATED O2 SATURATION)" 3018280305_1 CDM 301 RC 82803 HCPCS outpatient 212 159 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 186.56 88 999999999 165.36 201.4 percent of total billed charges "GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, CO2, HCO3 (INCLUDING CALCULATED O2 SATURATION)" 3018280305_1 CDM 301 RC 82803 HCPCS outpatient 212 159 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 188.68 89 999999999 165.36 201.4 percent of total billed charges "GLUCOSE, BODY FLUID, OTHER THAN BLOOD" 3018294501_1 CDM 301 RC 82945 HCPCS outpatient 91 68.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 81.9 90 999999999 70.98 86.45 percent of total billed charges "GLUCOSE, BODY FLUID, OTHER THAN BLOOD" 3018294501_1 CDM 301 RC 82945 HCPCS outpatient 91 68.25 AETNA MCR ADV AETNA MCR ADV 70.98 78 999999999 70.98 86.45 percent of total billed charges "GLUCOSE, BODY FLUID, OTHER THAN BLOOD" 3018294501_1 CDM 301 RC 82945 HCPCS outpatient 91 68.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 79.69 87.57 999999999 70.98 86.45 percent of total billed charges "GLUCOSE, BODY FLUID, OTHER THAN BLOOD" 3018294501_1 CDM 301 RC 82945 HCPCS outpatient 91 68.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 77.41 85.07 999999999 70.98 86.45 percent of total billed charges "GLUCOSE, BODY FLUID, OTHER THAN BLOOD" 3018294501_1 CDM 301 RC 82945 HCPCS outpatient 91 68.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 77.41 85.07 999999999 70.98 86.45 percent of total billed charges "GLUCOSE, BODY FLUID, OTHER THAN BLOOD" 3018294501_1 CDM 301 RC 82945 HCPCS outpatient 91 68.25 MOLINA MCAID MOLINA MCAID 75.89 83.4 999999999 70.98 86.45 percent of total billed charges "GLUCOSE, BODY FLUID, OTHER THAN BLOOD" 3018294501_1 CDM 301 RC 82945 HCPCS outpatient 91 68.25 MOLINA MCR ADV MOLINA MCR ADV 80.99 89 999999999 70.98 86.45 percent of total billed charges "GLUCOSE, BODY FLUID, OTHER THAN BLOOD" 3018294501_1 CDM 301 RC 82945 HCPCS outpatient 91 68.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 80.99 89 999999999 70.98 86.45 percent of total billed charges "GLUCOSE, BODY FLUID, OTHER THAN BLOOD" 3018294501_1 CDM 301 RC 82945 HCPCS outpatient 91 68.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 80.99 89 999999999 70.98 86.45 percent of total billed charges "GLUCOSE, BODY FLUID, OTHER THAN BLOOD" 3018294501_1 CDM 301 RC 82945 HCPCS outpatient 91 68.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 81.9 90 999999999 70.98 86.45 percent of total billed charges "GLUCOSE, BODY FLUID, OTHER THAN BLOOD" 3018294501_1 CDM 301 RC 82945 HCPCS outpatient 91 68.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 86.45 95 999999999 70.98 86.45 percent of total billed charges "GLUCOSE, BODY FLUID, OTHER THAN BLOOD" 3018294501_1 CDM 301 RC 82945 HCPCS outpatient 91 68.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 86.45 95 999999999 70.98 86.45 percent of total billed charges "GLUCOSE, BODY FLUID, OTHER THAN BLOOD" 3018294501_1 CDM 301 RC 82945 HCPCS outpatient 91 68.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 80.99 89 999999999 70.98 86.45 percent of total billed charges "GLUCOSE, BODY FLUID, OTHER THAN BLOOD" 3018294501_1 CDM 301 RC 82945 HCPCS outpatient 91 68.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 80.08 88 999999999 70.98 86.45 percent of total billed charges "GLUCOSE, BODY FLUID, OTHER THAN BLOOD" 3018294501_1 CDM 301 RC 82945 HCPCS outpatient 91 68.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 80.99 89 999999999 70.98 86.45 percent of total billed charges "GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT STRIP)" 3018294701_1 CDM 301 RC 82947 HCPCS outpatient 62 46.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 55.8 90 999999999 48.36 58.9 percent of total billed charges "GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT STRIP)" 3018294701_1 CDM 301 RC 82947 HCPCS outpatient 62 46.5 AETNA MCR ADV AETNA MCR ADV 48.36 78 999999999 48.36 58.9 percent of total billed charges "GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT STRIP)" 3018294701_1 CDM 301 RC 82947 HCPCS outpatient 62 46.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 54.29 87.57 999999999 48.36 58.9 percent of total billed charges "GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT STRIP)" 3018294701_1 CDM 301 RC 82947 HCPCS outpatient 62 46.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 52.74 85.07 999999999 48.36 58.9 percent of total billed charges "GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT STRIP)" 3018294701_1 CDM 301 RC 82947 HCPCS outpatient 62 46.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 52.74 85.07 999999999 48.36 58.9 percent of total billed charges "GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT STRIP)" 3018294701_1 CDM 301 RC 82947 HCPCS outpatient 62 46.5 MOLINA MCAID MOLINA MCAID 51.71 83.4 999999999 48.36 58.9 percent of total billed charges "GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT STRIP)" 3018294701_1 CDM 301 RC 82947 HCPCS outpatient 62 46.5 MOLINA MCR ADV MOLINA MCR ADV 55.18 89 999999999 48.36 58.9 percent of total billed charges "GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT STRIP)" 3018294701_1 CDM 301 RC 82947 HCPCS outpatient 62 46.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 55.18 89 999999999 48.36 58.9 percent of total billed charges "GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT STRIP)" 3018294701_1 CDM 301 RC 82947 HCPCS outpatient 62 46.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 55.18 89 999999999 48.36 58.9 percent of total billed charges "GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT STRIP)" 3018294701_1 CDM 301 RC 82947 HCPCS outpatient 62 46.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 55.8 90 999999999 48.36 58.9 percent of total billed charges "GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT STRIP)" 3018294701_1 CDM 301 RC 82947 HCPCS outpatient 62 46.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 58.9 95 999999999 48.36 58.9 percent of total billed charges "GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT STRIP)" 3018294701_1 CDM 301 RC 82947 HCPCS outpatient 62 46.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 58.9 95 999999999 48.36 58.9 percent of total billed charges "GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT STRIP)" 3018294701_1 CDM 301 RC 82947 HCPCS outpatient 62 46.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 55.18 89 999999999 48.36 58.9 percent of total billed charges "GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT STRIP)" 3018294701_1 CDM 301 RC 82947 HCPCS outpatient 62 46.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 54.56 88 999999999 48.36 58.9 percent of total billed charges "GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT STRIP)" 3018294701_1 CDM 301 RC 82947 HCPCS outpatient 62 46.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 55.18 89 999999999 48.36 58.9 percent of total billed charges GLUCOSE; POST GLUCOSE DOSE (INCLUDES GLUCOSE) 3018295001_1 CDM 301 RC 82950 HCPCS outpatient 57 42.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 51.3 90 999999999 44.46 54.15 percent of total billed charges GLUCOSE; POST GLUCOSE DOSE (INCLUDES GLUCOSE) 3018295001_1 CDM 301 RC 82950 HCPCS outpatient 57 42.75 AETNA MCR ADV AETNA MCR ADV 44.46 78 999999999 44.46 54.15 percent of total billed charges GLUCOSE; POST GLUCOSE DOSE (INCLUDES GLUCOSE) 3018295001_1 CDM 301 RC 82950 HCPCS outpatient 57 42.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 49.91 87.57 999999999 44.46 54.15 percent of total billed charges GLUCOSE; POST GLUCOSE DOSE (INCLUDES GLUCOSE) 3018295001_1 CDM 301 RC 82950 HCPCS outpatient 57 42.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 48.49 85.07 999999999 44.46 54.15 percent of total billed charges GLUCOSE; POST GLUCOSE DOSE (INCLUDES GLUCOSE) 3018295001_1 CDM 301 RC 82950 HCPCS outpatient 57 42.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 48.49 85.07 999999999 44.46 54.15 percent of total billed charges GLUCOSE; POST GLUCOSE DOSE (INCLUDES GLUCOSE) 3018295001_1 CDM 301 RC 82950 HCPCS outpatient 57 42.75 MOLINA MCAID MOLINA MCAID 47.54 83.4 999999999 44.46 54.15 percent of total billed charges GLUCOSE; POST GLUCOSE DOSE (INCLUDES GLUCOSE) 3018295001_1 CDM 301 RC 82950 HCPCS outpatient 57 42.75 MOLINA MCR ADV MOLINA MCR ADV 50.73 89 999999999 44.46 54.15 percent of total billed charges GLUCOSE; POST GLUCOSE DOSE (INCLUDES GLUCOSE) 3018295001_1 CDM 301 RC 82950 HCPCS outpatient 57 42.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50.73 89 999999999 44.46 54.15 percent of total billed charges GLUCOSE; POST GLUCOSE DOSE (INCLUDES GLUCOSE) 3018295001_1 CDM 301 RC 82950 HCPCS outpatient 57 42.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50.73 89 999999999 44.46 54.15 percent of total billed charges GLUCOSE; POST GLUCOSE DOSE (INCLUDES GLUCOSE) 3018295001_1 CDM 301 RC 82950 HCPCS outpatient 57 42.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 51.3 90 999999999 44.46 54.15 percent of total billed charges GLUCOSE; POST GLUCOSE DOSE (INCLUDES GLUCOSE) 3018295001_1 CDM 301 RC 82950 HCPCS outpatient 57 42.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 54.15 95 999999999 44.46 54.15 percent of total billed charges GLUCOSE; POST GLUCOSE DOSE (INCLUDES GLUCOSE) 3018295001_1 CDM 301 RC 82950 HCPCS outpatient 57 42.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 54.15 95 999999999 44.46 54.15 percent of total billed charges GLUCOSE; POST GLUCOSE DOSE (INCLUDES GLUCOSE) 3018295001_1 CDM 301 RC 82950 HCPCS outpatient 57 42.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50.73 89 999999999 44.46 54.15 percent of total billed charges GLUCOSE; POST GLUCOSE DOSE (INCLUDES GLUCOSE) 3018295001_1 CDM 301 RC 82950 HCPCS outpatient 57 42.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50.16 88 999999999 44.46 54.15 percent of total billed charges GLUCOSE; POST GLUCOSE DOSE (INCLUDES GLUCOSE) 3018295001_1 CDM 301 RC 82950 HCPCS outpatient 57 42.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50.73 89 999999999 44.46 54.15 percent of total billed charges "GLUCOSE; TOLERANCE TEST (GTT), 3 SPECIMENS (INCLUDES GLUCOSE)" 3018295101_1 CDM 301 RC 82951 HCPCS outpatient 109 81.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 98.1 90 999999999 85.02 103.55 percent of total billed charges "GLUCOSE; TOLERANCE TEST (GTT), 3 SPECIMENS (INCLUDES GLUCOSE)" 3018295101_1 CDM 301 RC 82951 HCPCS outpatient 109 81.75 AETNA MCR ADV AETNA MCR ADV 85.02 78 999999999 85.02 103.55 percent of total billed charges "GLUCOSE; TOLERANCE TEST (GTT), 3 SPECIMENS (INCLUDES GLUCOSE)" 3018295101_1 CDM 301 RC 82951 HCPCS outpatient 109 81.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 95.45 87.57 999999999 85.02 103.55 percent of total billed charges "GLUCOSE; TOLERANCE TEST (GTT), 3 SPECIMENS (INCLUDES GLUCOSE)" 3018295101_1 CDM 301 RC 82951 HCPCS outpatient 109 81.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 92.73 85.07 999999999 85.02 103.55 percent of total billed charges "GLUCOSE; TOLERANCE TEST (GTT), 3 SPECIMENS (INCLUDES GLUCOSE)" 3018295101_1 CDM 301 RC 82951 HCPCS outpatient 109 81.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 92.73 85.07 999999999 85.02 103.55 percent of total billed charges "GLUCOSE; TOLERANCE TEST (GTT), 3 SPECIMENS (INCLUDES GLUCOSE)" 3018295101_1 CDM 301 RC 82951 HCPCS outpatient 109 81.75 MOLINA MCAID MOLINA MCAID 90.91 83.4 999999999 85.02 103.55 percent of total billed charges "GLUCOSE; TOLERANCE TEST (GTT), 3 SPECIMENS (INCLUDES GLUCOSE)" 3018295101_1 CDM 301 RC 82951 HCPCS outpatient 109 81.75 MOLINA MCR ADV MOLINA MCR ADV 97.01 89 999999999 85.02 103.55 percent of total billed charges "GLUCOSE; TOLERANCE TEST (GTT), 3 SPECIMENS (INCLUDES GLUCOSE)" 3018295101_1 CDM 301 RC 82951 HCPCS outpatient 109 81.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 97.01 89 999999999 85.02 103.55 percent of total billed charges "GLUCOSE; TOLERANCE TEST (GTT), 3 SPECIMENS (INCLUDES GLUCOSE)" 3018295101_1 CDM 301 RC 82951 HCPCS outpatient 109 81.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 97.01 89 999999999 85.02 103.55 percent of total billed charges "GLUCOSE; TOLERANCE TEST (GTT), 3 SPECIMENS (INCLUDES GLUCOSE)" 3018295101_1 CDM 301 RC 82951 HCPCS outpatient 109 81.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 98.1 90 999999999 85.02 103.55 percent of total billed charges "GLUCOSE; TOLERANCE TEST (GTT), 3 SPECIMENS (INCLUDES GLUCOSE)" 3018295101_1 CDM 301 RC 82951 HCPCS outpatient 109 81.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 103.55 95 999999999 85.02 103.55 percent of total billed charges "GLUCOSE; TOLERANCE TEST (GTT), 3 SPECIMENS (INCLUDES GLUCOSE)" 3018295101_1 CDM 301 RC 82951 HCPCS outpatient 109 81.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 103.55 95 999999999 85.02 103.55 percent of total billed charges "GLUCOSE; TOLERANCE TEST (GTT), 3 SPECIMENS (INCLUDES GLUCOSE)" 3018295101_1 CDM 301 RC 82951 HCPCS outpatient 109 81.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 97.01 89 999999999 85.02 103.55 percent of total billed charges "GLUCOSE; TOLERANCE TEST (GTT), 3 SPECIMENS (INCLUDES GLUCOSE)" 3018295101_1 CDM 301 RC 82951 HCPCS outpatient 109 81.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 95.92 88 999999999 85.02 103.55 percent of total billed charges "GLUCOSE; TOLERANCE TEST (GTT), 3 SPECIMENS (INCLUDES GLUCOSE)" 3018295101_1 CDM 301 RC 82951 HCPCS outpatient 109 81.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 97.01 89 999999999 85.02 103.55 percent of total billed charges "GLUCOSE; TOLERANCE TEST, EACH ADDITIONAL BEYOND 3 SPECIMENS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 3018295201_1 CDM 301 RC 82952 HCPCS outpatient 42 31.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 37.8 90 999999999 32.76 39.9 percent of total billed charges "GLUCOSE; TOLERANCE TEST, EACH ADDITIONAL BEYOND 3 SPECIMENS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 3018295201_1 CDM 301 RC 82952 HCPCS outpatient 42 31.5 AETNA MCR ADV AETNA MCR ADV 32.76 78 999999999 32.76 39.9 percent of total billed charges "GLUCOSE; TOLERANCE TEST, EACH ADDITIONAL BEYOND 3 SPECIMENS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 3018295201_1 CDM 301 RC 82952 HCPCS outpatient 42 31.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 36.78 87.57 999999999 32.76 39.9 percent of total billed charges "GLUCOSE; TOLERANCE TEST, EACH ADDITIONAL BEYOND 3 SPECIMENS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 3018295201_1 CDM 301 RC 82952 HCPCS outpatient 42 31.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 35.73 85.07 999999999 32.76 39.9 percent of total billed charges "GLUCOSE; TOLERANCE TEST, EACH ADDITIONAL BEYOND 3 SPECIMENS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 3018295201_1 CDM 301 RC 82952 HCPCS outpatient 42 31.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 35.73 85.07 999999999 32.76 39.9 percent of total billed charges "GLUCOSE; TOLERANCE TEST, EACH ADDITIONAL BEYOND 3 SPECIMENS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 3018295201_1 CDM 301 RC 82952 HCPCS outpatient 42 31.5 MOLINA MCAID MOLINA MCAID 35.03 83.4 999999999 32.76 39.9 percent of total billed charges "GLUCOSE; TOLERANCE TEST, EACH ADDITIONAL BEYOND 3 SPECIMENS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 3018295201_1 CDM 301 RC 82952 HCPCS outpatient 42 31.5 MOLINA MCR ADV MOLINA MCR ADV 37.38 89 999999999 32.76 39.9 percent of total billed charges "GLUCOSE; TOLERANCE TEST, EACH ADDITIONAL BEYOND 3 SPECIMENS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 3018295201_1 CDM 301 RC 82952 HCPCS outpatient 42 31.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 37.38 89 999999999 32.76 39.9 percent of total billed charges "GLUCOSE; TOLERANCE TEST, EACH ADDITIONAL BEYOND 3 SPECIMENS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 3018295201_1 CDM 301 RC 82952 HCPCS outpatient 42 31.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 37.38 89 999999999 32.76 39.9 percent of total billed charges "GLUCOSE; TOLERANCE TEST, EACH ADDITIONAL BEYOND 3 SPECIMENS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 3018295201_1 CDM 301 RC 82952 HCPCS outpatient 42 31.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 37.8 90 999999999 32.76 39.9 percent of total billed charges "GLUCOSE; TOLERANCE TEST, EACH ADDITIONAL BEYOND 3 SPECIMENS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 3018295201_1 CDM 301 RC 82952 HCPCS outpatient 42 31.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 39.9 95 999999999 32.76 39.9 percent of total billed charges "GLUCOSE; TOLERANCE TEST, EACH ADDITIONAL BEYOND 3 SPECIMENS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 3018295201_1 CDM 301 RC 82952 HCPCS outpatient 42 31.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 39.9 95 999999999 32.76 39.9 percent of total billed charges "GLUCOSE; TOLERANCE TEST, EACH ADDITIONAL BEYOND 3 SPECIMENS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 3018295201_1 CDM 301 RC 82952 HCPCS outpatient 42 31.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 37.38 89 999999999 32.76 39.9 percent of total billed charges "GLUCOSE; TOLERANCE TEST, EACH ADDITIONAL BEYOND 3 SPECIMENS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 3018295201_1 CDM 301 RC 82952 HCPCS outpatient 42 31.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 36.96 88 999999999 32.76 39.9 percent of total billed charges "GLUCOSE; TOLERANCE TEST, EACH ADDITIONAL BEYOND 3 SPECIMENS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 3018295201_1 CDM 301 RC 82952 HCPCS outpatient 42 31.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 37.38 89 999999999 32.76 39.9 percent of total billed charges "GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) CLEARED BY THE FDA SPECIFICALLY FOR HOME USE" 3018296201_1 CDM 301 RC 82962 HCPCS outpatient 29 21.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 26.1 90 999999999 22.62 27.55 percent of total billed charges "GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) CLEARED BY THE FDA SPECIFICALLY FOR HOME USE" 3018296201_1 CDM 301 RC 82962 HCPCS outpatient 29 21.75 AETNA MCR ADV AETNA MCR ADV 22.62 78 999999999 22.62 27.55 percent of total billed charges "GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) CLEARED BY THE FDA SPECIFICALLY FOR HOME USE" 3018296201_1 CDM 301 RC 82962 HCPCS outpatient 29 21.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 25.4 87.57 999999999 22.62 27.55 percent of total billed charges "GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) CLEARED BY THE FDA SPECIFICALLY FOR HOME USE" 3018296201_1 CDM 301 RC 82962 HCPCS outpatient 29 21.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 24.67 85.07 999999999 22.62 27.55 percent of total billed charges "GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) CLEARED BY THE FDA SPECIFICALLY FOR HOME USE" 3018296201_1 CDM 301 RC 82962 HCPCS outpatient 29 21.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 24.67 85.07 999999999 22.62 27.55 percent of total billed charges "GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) CLEARED BY THE FDA SPECIFICALLY FOR HOME USE" 3018296201_1 CDM 301 RC 82962 HCPCS outpatient 29 21.75 MOLINA MCAID MOLINA MCAID 24.19 83.4 999999999 22.62 27.55 percent of total billed charges "GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) CLEARED BY THE FDA SPECIFICALLY FOR HOME USE" 3018296201_1 CDM 301 RC 82962 HCPCS outpatient 29 21.75 MOLINA MCR ADV MOLINA MCR ADV 25.81 89 999999999 22.62 27.55 percent of total billed charges "GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) CLEARED BY THE FDA SPECIFICALLY FOR HOME USE" 3018296201_1 CDM 301 RC 82962 HCPCS outpatient 29 21.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 25.81 89 999999999 22.62 27.55 percent of total billed charges "GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) CLEARED BY THE FDA SPECIFICALLY FOR HOME USE" 3018296201_1 CDM 301 RC 82962 HCPCS outpatient 29 21.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 25.81 89 999999999 22.62 27.55 percent of total billed charges "GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) CLEARED BY THE FDA SPECIFICALLY FOR HOME USE" 3018296201_1 CDM 301 RC 82962 HCPCS outpatient 29 21.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 26.1 90 999999999 22.62 27.55 percent of total billed charges "GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) CLEARED BY THE FDA SPECIFICALLY FOR HOME USE" 3018296201_1 CDM 301 RC 82962 HCPCS outpatient 29 21.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 27.55 95 999999999 22.62 27.55 percent of total billed charges "GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) CLEARED BY THE FDA SPECIFICALLY FOR HOME USE" 3018296201_1 CDM 301 RC 82962 HCPCS outpatient 29 21.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 27.55 95 999999999 22.62 27.55 percent of total billed charges "GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) CLEARED BY THE FDA SPECIFICALLY FOR HOME USE" 3018296201_1 CDM 301 RC 82962 HCPCS outpatient 29 21.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 25.81 89 999999999 22.62 27.55 percent of total billed charges "GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) CLEARED BY THE FDA SPECIFICALLY FOR HOME USE" 3018296201_1 CDM 301 RC 82962 HCPCS outpatient 29 21.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 25.52 88 999999999 22.62 27.55 percent of total billed charges "GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) CLEARED BY THE FDA SPECIFICALLY FOR HOME USE" 3018296201_1 CDM 301 RC 82962 HCPCS outpatient 29 21.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 25.81 89 999999999 22.62 27.55 percent of total billed charges "GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) CLEARED BY THE FDA SPECIFICALLY FOR HOME USE" 3018296201_2 CDM 301 RC 82962 HCPCS outpatient 29 21.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 26.1 90 999999999 22.62 27.55 percent of total billed charges "GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) CLEARED BY THE FDA SPECIFICALLY FOR HOME USE" 3018296201_2 CDM 301 RC 82962 HCPCS outpatient 29 21.75 AETNA MCR ADV AETNA MCR ADV 22.62 78 999999999 22.62 27.55 percent of total billed charges "GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) CLEARED BY THE FDA SPECIFICALLY FOR HOME USE" 3018296201_2 CDM 301 RC 82962 HCPCS outpatient 29 21.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 25.4 87.57 999999999 22.62 27.55 percent of total billed charges "GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) CLEARED BY THE FDA SPECIFICALLY FOR HOME USE" 3018296201_2 CDM 301 RC 82962 HCPCS outpatient 29 21.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 24.67 85.07 999999999 22.62 27.55 percent of total billed charges "GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) CLEARED BY THE FDA SPECIFICALLY FOR HOME USE" 3018296201_2 CDM 301 RC 82962 HCPCS outpatient 29 21.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 24.67 85.07 999999999 22.62 27.55 percent of total billed charges "GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) CLEARED BY THE FDA SPECIFICALLY FOR HOME USE" 3018296201_2 CDM 301 RC 82962 HCPCS outpatient 29 21.75 MOLINA MCAID MOLINA MCAID 24.19 83.4 999999999 22.62 27.55 percent of total billed charges "GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) CLEARED BY THE FDA SPECIFICALLY FOR HOME USE" 3018296201_2 CDM 301 RC 82962 HCPCS outpatient 29 21.75 MOLINA MCR ADV MOLINA MCR ADV 25.81 89 999999999 22.62 27.55 percent of total billed charges "GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) CLEARED BY THE FDA SPECIFICALLY FOR HOME USE" 3018296201_2 CDM 301 RC 82962 HCPCS outpatient 29 21.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 25.81 89 999999999 22.62 27.55 percent of total billed charges "GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) CLEARED BY THE FDA SPECIFICALLY FOR HOME USE" 3018296201_2 CDM 301 RC 82962 HCPCS outpatient 29 21.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 25.81 89 999999999 22.62 27.55 percent of total billed charges "GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) CLEARED BY THE FDA SPECIFICALLY FOR HOME USE" 3018296201_2 CDM 301 RC 82962 HCPCS outpatient 29 21.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 26.1 90 999999999 22.62 27.55 percent of total billed charges "GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) CLEARED BY THE FDA SPECIFICALLY FOR HOME USE" 3018296201_2 CDM 301 RC 82962 HCPCS outpatient 29 21.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 27.55 95 999999999 22.62 27.55 percent of total billed charges "GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) CLEARED BY THE FDA SPECIFICALLY FOR HOME USE" 3018296201_2 CDM 301 RC 82962 HCPCS outpatient 29 21.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 27.55 95 999999999 22.62 27.55 percent of total billed charges "GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) CLEARED BY THE FDA SPECIFICALLY FOR HOME USE" 3018296201_2 CDM 301 RC 82962 HCPCS outpatient 29 21.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 25.81 89 999999999 22.62 27.55 percent of total billed charges "GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) CLEARED BY THE FDA SPECIFICALLY FOR HOME USE" 3018296201_2 CDM 301 RC 82962 HCPCS outpatient 29 21.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 25.52 88 999999999 22.62 27.55 percent of total billed charges "GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) CLEARED BY THE FDA SPECIFICALLY FOR HOME USE" 3018296201_2 CDM 301 RC 82962 HCPCS outpatient 29 21.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 25.81 89 999999999 22.62 27.55 percent of total billed charges "GLUTAMYLTRANSFERASE, GAMMA (GGT)" 3018297701_1 CDM 301 RC 82977 HCPCS outpatient 69 51.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 62.1 90 999999999 53.82 65.55 percent of total billed charges "GLUTAMYLTRANSFERASE, GAMMA (GGT)" 3018297701_1 CDM 301 RC 82977 HCPCS outpatient 69 51.75 AETNA MCR ADV AETNA MCR ADV 53.82 78 999999999 53.82 65.55 percent of total billed charges "GLUTAMYLTRANSFERASE, GAMMA (GGT)" 3018297701_1 CDM 301 RC 82977 HCPCS outpatient 69 51.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 60.42 87.57 999999999 53.82 65.55 percent of total billed charges "GLUTAMYLTRANSFERASE, GAMMA (GGT)" 3018297701_1 CDM 301 RC 82977 HCPCS outpatient 69 51.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 58.7 85.07 999999999 53.82 65.55 percent of total billed charges "GLUTAMYLTRANSFERASE, GAMMA (GGT)" 3018297701_1 CDM 301 RC 82977 HCPCS outpatient 69 51.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 58.7 85.07 999999999 53.82 65.55 percent of total billed charges "GLUTAMYLTRANSFERASE, GAMMA (GGT)" 3018297701_1 CDM 301 RC 82977 HCPCS outpatient 69 51.75 MOLINA MCAID MOLINA MCAID 57.55 83.4 999999999 53.82 65.55 percent of total billed charges "GLUTAMYLTRANSFERASE, GAMMA (GGT)" 3018297701_1 CDM 301 RC 82977 HCPCS outpatient 69 51.75 MOLINA MCR ADV MOLINA MCR ADV 61.41 89 999999999 53.82 65.55 percent of total billed charges "GLUTAMYLTRANSFERASE, GAMMA (GGT)" 3018297701_1 CDM 301 RC 82977 HCPCS outpatient 69 51.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 61.41 89 999999999 53.82 65.55 percent of total billed charges "GLUTAMYLTRANSFERASE, GAMMA (GGT)" 3018297701_1 CDM 301 RC 82977 HCPCS outpatient 69 51.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 61.41 89 999999999 53.82 65.55 percent of total billed charges "GLUTAMYLTRANSFERASE, GAMMA (GGT)" 3018297701_1 CDM 301 RC 82977 HCPCS outpatient 69 51.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 62.1 90 999999999 53.82 65.55 percent of total billed charges "GLUTAMYLTRANSFERASE, GAMMA (GGT)" 3018297701_1 CDM 301 RC 82977 HCPCS outpatient 69 51.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 65.55 95 999999999 53.82 65.55 percent of total billed charges "GLUTAMYLTRANSFERASE, GAMMA (GGT)" 3018297701_1 CDM 301 RC 82977 HCPCS outpatient 69 51.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 65.55 95 999999999 53.82 65.55 percent of total billed charges "GLUTAMYLTRANSFERASE, GAMMA (GGT)" 3018297701_1 CDM 301 RC 82977 HCPCS outpatient 69 51.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 61.41 89 999999999 53.82 65.55 percent of total billed charges "GLUTAMYLTRANSFERASE, GAMMA (GGT)" 3018297701_1 CDM 301 RC 82977 HCPCS outpatient 69 51.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 60.72 88 999999999 53.82 65.55 percent of total billed charges "GLUTAMYLTRANSFERASE, GAMMA (GGT)" 3018297701_1 CDM 301 RC 82977 HCPCS outpatient 69 51.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 61.41 89 999999999 53.82 65.55 percent of total billed charges GONADOTROPIN; FOLLICLE STIMULATING HORMONE (FSH) 3018300101_1 CDM 301 RC 83001 HCPCS outpatient 125 93.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 112.5 90 999999999 97.5 118.75 percent of total billed charges GONADOTROPIN; FOLLICLE STIMULATING HORMONE (FSH) 3018300101_1 CDM 301 RC 83001 HCPCS outpatient 125 93.75 AETNA MCR ADV AETNA MCR ADV 97.5 78 999999999 97.5 118.75 percent of total billed charges GONADOTROPIN; FOLLICLE STIMULATING HORMONE (FSH) 3018300101_1 CDM 301 RC 83001 HCPCS outpatient 125 93.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 109.46 87.57 999999999 97.5 118.75 percent of total billed charges GONADOTROPIN; FOLLICLE STIMULATING HORMONE (FSH) 3018300101_1 CDM 301 RC 83001 HCPCS outpatient 125 93.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 106.34 85.07 999999999 97.5 118.75 percent of total billed charges GONADOTROPIN; FOLLICLE STIMULATING HORMONE (FSH) 3018300101_1 CDM 301 RC 83001 HCPCS outpatient 125 93.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 106.34 85.07 999999999 97.5 118.75 percent of total billed charges GONADOTROPIN; FOLLICLE STIMULATING HORMONE (FSH) 3018300101_1 CDM 301 RC 83001 HCPCS outpatient 125 93.75 MOLINA MCAID MOLINA MCAID 104.25 83.4 999999999 97.5 118.75 percent of total billed charges GONADOTROPIN; FOLLICLE STIMULATING HORMONE (FSH) 3018300101_1 CDM 301 RC 83001 HCPCS outpatient 125 93.75 MOLINA MCR ADV MOLINA MCR ADV 111.25 89 999999999 97.5 118.75 percent of total billed charges GONADOTROPIN; FOLLICLE STIMULATING HORMONE (FSH) 3018300101_1 CDM 301 RC 83001 HCPCS outpatient 125 93.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 111.25 89 999999999 97.5 118.75 percent of total billed charges GONADOTROPIN; FOLLICLE STIMULATING HORMONE (FSH) 3018300101_1 CDM 301 RC 83001 HCPCS outpatient 125 93.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 111.25 89 999999999 97.5 118.75 percent of total billed charges GONADOTROPIN; FOLLICLE STIMULATING HORMONE (FSH) 3018300101_1 CDM 301 RC 83001 HCPCS outpatient 125 93.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 112.5 90 999999999 97.5 118.75 percent of total billed charges GONADOTROPIN; FOLLICLE STIMULATING HORMONE (FSH) 3018300101_1 CDM 301 RC 83001 HCPCS outpatient 125 93.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 118.75 95 999999999 97.5 118.75 percent of total billed charges GONADOTROPIN; FOLLICLE STIMULATING HORMONE (FSH) 3018300101_1 CDM 301 RC 83001 HCPCS outpatient 125 93.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 118.75 95 999999999 97.5 118.75 percent of total billed charges GONADOTROPIN; FOLLICLE STIMULATING HORMONE (FSH) 3018300101_1 CDM 301 RC 83001 HCPCS outpatient 125 93.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 111.25 89 999999999 97.5 118.75 percent of total billed charges GONADOTROPIN; FOLLICLE STIMULATING HORMONE (FSH) 3018300101_1 CDM 301 RC 83001 HCPCS outpatient 125 93.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 110 88 999999999 97.5 118.75 percent of total billed charges GONADOTROPIN; FOLLICLE STIMULATING HORMONE (FSH) 3018300101_1 CDM 301 RC 83001 HCPCS outpatient 125 93.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 111.25 89 999999999 97.5 118.75 percent of total billed charges GONADOTROPIN; LUTEINIZING HORMONE (LH) 3018300201_1 CDM 301 RC 83002 HCPCS outpatient 124 93 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 111.6 90 999999999 96.72 117.8 percent of total billed charges GONADOTROPIN; LUTEINIZING HORMONE (LH) 3018300201_1 CDM 301 RC 83002 HCPCS outpatient 124 93 AETNA MCR ADV AETNA MCR ADV 96.72 78 999999999 96.72 117.8 percent of total billed charges GONADOTROPIN; LUTEINIZING HORMONE (LH) 3018300201_1 CDM 301 RC 83002 HCPCS outpatient 124 93 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 108.59 87.57 999999999 96.72 117.8 percent of total billed charges GONADOTROPIN; LUTEINIZING HORMONE (LH) 3018300201_1 CDM 301 RC 83002 HCPCS outpatient 124 93 COORDINATED CARE MCAID COORDINATED CARE MCAID 105.49 85.07 999999999 96.72 117.8 percent of total billed charges GONADOTROPIN; LUTEINIZING HORMONE (LH) 3018300201_1 CDM 301 RC 83002 HCPCS outpatient 124 93 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 105.49 85.07 999999999 96.72 117.8 percent of total billed charges GONADOTROPIN; LUTEINIZING HORMONE (LH) 3018300201_1 CDM 301 RC 83002 HCPCS outpatient 124 93 MOLINA MCAID MOLINA MCAID 103.42 83.4 999999999 96.72 117.8 percent of total billed charges GONADOTROPIN; LUTEINIZING HORMONE (LH) 3018300201_1 CDM 301 RC 83002 HCPCS outpatient 124 93 MOLINA MCR ADV MOLINA MCR ADV 110.36 89 999999999 96.72 117.8 percent of total billed charges GONADOTROPIN; LUTEINIZING HORMONE (LH) 3018300201_1 CDM 301 RC 83002 HCPCS outpatient 124 93 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 110.36 89 999999999 96.72 117.8 percent of total billed charges GONADOTROPIN; LUTEINIZING HORMONE (LH) 3018300201_1 CDM 301 RC 83002 HCPCS outpatient 124 93 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 110.36 89 999999999 96.72 117.8 percent of total billed charges GONADOTROPIN; LUTEINIZING HORMONE (LH) 3018300201_1 CDM 301 RC 83002 HCPCS outpatient 124 93 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 111.6 90 999999999 96.72 117.8 percent of total billed charges GONADOTROPIN; LUTEINIZING HORMONE (LH) 3018300201_1 CDM 301 RC 83002 HCPCS outpatient 124 93 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 117.8 95 999999999 96.72 117.8 percent of total billed charges GONADOTROPIN; LUTEINIZING HORMONE (LH) 3018300201_1 CDM 301 RC 83002 HCPCS outpatient 124 93 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 117.8 95 999999999 96.72 117.8 percent of total billed charges GONADOTROPIN; LUTEINIZING HORMONE (LH) 3018300201_1 CDM 301 RC 83002 HCPCS outpatient 124 93 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 110.36 89 999999999 96.72 117.8 percent of total billed charges GONADOTROPIN; LUTEINIZING HORMONE (LH) 3018300201_1 CDM 301 RC 83002 HCPCS outpatient 124 93 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 109.12 88 999999999 96.72 117.8 percent of total billed charges GONADOTROPIN; LUTEINIZING HORMONE (LH) 3018300201_1 CDM 301 RC 83002 HCPCS outpatient 124 93 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 110.36 89 999999999 96.72 117.8 percent of total billed charges HAPTOGLOBIN; QUANTITATIVE 3018301002_1 CDM 301 RC 83010 HCPCS outpatient 164 123 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 147.6 90 999999999 127.92 155.8 percent of total billed charges HAPTOGLOBIN; QUANTITATIVE 3018301002_1 CDM 301 RC 83010 HCPCS outpatient 164 123 AETNA MCR ADV AETNA MCR ADV 127.92 78 999999999 127.92 155.8 percent of total billed charges HAPTOGLOBIN; QUANTITATIVE 3018301002_1 CDM 301 RC 83010 HCPCS outpatient 164 123 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 143.61 87.57 999999999 127.92 155.8 percent of total billed charges HAPTOGLOBIN; QUANTITATIVE 3018301002_1 CDM 301 RC 83010 HCPCS outpatient 164 123 COORDINATED CARE MCAID COORDINATED CARE MCAID 139.51 85.07 999999999 127.92 155.8 percent of total billed charges HAPTOGLOBIN; QUANTITATIVE 3018301002_1 CDM 301 RC 83010 HCPCS outpatient 164 123 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 139.51 85.07 999999999 127.92 155.8 percent of total billed charges HAPTOGLOBIN; QUANTITATIVE 3018301002_1 CDM 301 RC 83010 HCPCS outpatient 164 123 MOLINA MCAID MOLINA MCAID 136.78 83.4 999999999 127.92 155.8 percent of total billed charges HAPTOGLOBIN; QUANTITATIVE 3018301002_1 CDM 301 RC 83010 HCPCS outpatient 164 123 MOLINA MCR ADV MOLINA MCR ADV 145.96 89 999999999 127.92 155.8 percent of total billed charges HAPTOGLOBIN; QUANTITATIVE 3018301002_1 CDM 301 RC 83010 HCPCS outpatient 164 123 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 145.96 89 999999999 127.92 155.8 percent of total billed charges HAPTOGLOBIN; QUANTITATIVE 3018301002_1 CDM 301 RC 83010 HCPCS outpatient 164 123 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 145.96 89 999999999 127.92 155.8 percent of total billed charges HAPTOGLOBIN; QUANTITATIVE 3018301002_1 CDM 301 RC 83010 HCPCS outpatient 164 123 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 147.6 90 999999999 127.92 155.8 percent of total billed charges HAPTOGLOBIN; QUANTITATIVE 3018301002_1 CDM 301 RC 83010 HCPCS outpatient 164 123 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 155.8 95 999999999 127.92 155.8 percent of total billed charges HAPTOGLOBIN; QUANTITATIVE 3018301002_1 CDM 301 RC 83010 HCPCS outpatient 164 123 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 155.8 95 999999999 127.92 155.8 percent of total billed charges HAPTOGLOBIN; QUANTITATIVE 3018301002_1 CDM 301 RC 83010 HCPCS outpatient 164 123 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 145.96 89 999999999 127.92 155.8 percent of total billed charges HAPTOGLOBIN; QUANTITATIVE 3018301002_1 CDM 301 RC 83010 HCPCS outpatient 164 123 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 144.32 88 999999999 127.92 155.8 percent of total billed charges HAPTOGLOBIN; QUANTITATIVE 3018301002_1 CDM 301 RC 83010 HCPCS outpatient 164 123 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 145.96 89 999999999 127.92 155.8 percent of total billed charges "HELICOBACTER PYLORI; BREATH TEST ANALYSIS FOR UREASE ACTIVITY, NON-RADIOACTIVE ISOTOPE (EG, C-13)" 3018301302_1 CDM 301 RC 83013 HCPCS outpatient 283 212.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 254.7 90 999999999 220.74 268.85 percent of total billed charges "HELICOBACTER PYLORI; BREATH TEST ANALYSIS FOR UREASE ACTIVITY, NON-RADIOACTIVE ISOTOPE (EG, C-13)" 3018301302_1 CDM 301 RC 83013 HCPCS outpatient 283 212.25 AETNA MCR ADV AETNA MCR ADV 220.74 78 999999999 220.74 268.85 percent of total billed charges "HELICOBACTER PYLORI; BREATH TEST ANALYSIS FOR UREASE ACTIVITY, NON-RADIOACTIVE ISOTOPE (EG, C-13)" 3018301302_1 CDM 301 RC 83013 HCPCS outpatient 283 212.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 247.82 87.57 999999999 220.74 268.85 percent of total billed charges "HELICOBACTER PYLORI; BREATH TEST ANALYSIS FOR UREASE ACTIVITY, NON-RADIOACTIVE ISOTOPE (EG, C-13)" 3018301302_1 CDM 301 RC 83013 HCPCS outpatient 283 212.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 240.75 85.07 999999999 220.74 268.85 percent of total billed charges "HELICOBACTER PYLORI; BREATH TEST ANALYSIS FOR UREASE ACTIVITY, NON-RADIOACTIVE ISOTOPE (EG, C-13)" 3018301302_1 CDM 301 RC 83013 HCPCS outpatient 283 212.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 240.75 85.07 999999999 220.74 268.85 percent of total billed charges "HELICOBACTER PYLORI; BREATH TEST ANALYSIS FOR UREASE ACTIVITY, NON-RADIOACTIVE ISOTOPE (EG, C-13)" 3018301302_1 CDM 301 RC 83013 HCPCS outpatient 283 212.25 MOLINA MCAID MOLINA MCAID 236.02 83.4 999999999 220.74 268.85 percent of total billed charges "HELICOBACTER PYLORI; BREATH TEST ANALYSIS FOR UREASE ACTIVITY, NON-RADIOACTIVE ISOTOPE (EG, C-13)" 3018301302_1 CDM 301 RC 83013 HCPCS outpatient 283 212.25 MOLINA MCR ADV MOLINA MCR ADV 251.87 89 999999999 220.74 268.85 percent of total billed charges "HELICOBACTER PYLORI; BREATH TEST ANALYSIS FOR UREASE ACTIVITY, NON-RADIOACTIVE ISOTOPE (EG, C-13)" 3018301302_1 CDM 301 RC 83013 HCPCS outpatient 283 212.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 251.87 89 999999999 220.74 268.85 percent of total billed charges "HELICOBACTER PYLORI; BREATH TEST ANALYSIS FOR UREASE ACTIVITY, NON-RADIOACTIVE ISOTOPE (EG, C-13)" 3018301302_1 CDM 301 RC 83013 HCPCS outpatient 283 212.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 251.87 89 999999999 220.74 268.85 percent of total billed charges "HELICOBACTER PYLORI; BREATH TEST ANALYSIS FOR UREASE ACTIVITY, NON-RADIOACTIVE ISOTOPE (EG, C-13)" 3018301302_1 CDM 301 RC 83013 HCPCS outpatient 283 212.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 254.7 90 999999999 220.74 268.85 percent of total billed charges "HELICOBACTER PYLORI; BREATH TEST ANALYSIS FOR UREASE ACTIVITY, NON-RADIOACTIVE ISOTOPE (EG, C-13)" 3018301302_1 CDM 301 RC 83013 HCPCS outpatient 283 212.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 268.85 95 999999999 220.74 268.85 percent of total billed charges "HELICOBACTER PYLORI; BREATH TEST ANALYSIS FOR UREASE ACTIVITY, NON-RADIOACTIVE ISOTOPE (EG, C-13)" 3018301302_1 CDM 301 RC 83013 HCPCS outpatient 283 212.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 268.85 95 999999999 220.74 268.85 percent of total billed charges "HELICOBACTER PYLORI; BREATH TEST ANALYSIS FOR UREASE ACTIVITY, NON-RADIOACTIVE ISOTOPE (EG, C-13)" 3018301302_1 CDM 301 RC 83013 HCPCS outpatient 283 212.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 251.87 89 999999999 220.74 268.85 percent of total billed charges "HELICOBACTER PYLORI; BREATH TEST ANALYSIS FOR UREASE ACTIVITY, NON-RADIOACTIVE ISOTOPE (EG, C-13)" 3018301302_1 CDM 301 RC 83013 HCPCS outpatient 283 212.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 249.04 88 999999999 220.74 268.85 percent of total billed charges "HELICOBACTER PYLORI; BREATH TEST ANALYSIS FOR UREASE ACTIVITY, NON-RADIOACTIVE ISOTOPE (EG, C-13)" 3018301302_1 CDM 301 RC 83013 HCPCS outpatient 283 212.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 251.87 89 999999999 220.74 268.85 percent of total billed charges HEMOGLOBIN; GLYCOSYLATED (A1C) 3018303601_1 CDM 301 RC 83036 HCPCS outpatient 91 68.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 81.9 90 999999999 70.98 86.45 percent of total billed charges HEMOGLOBIN; GLYCOSYLATED (A1C) 3018303601_1 CDM 301 RC 83036 HCPCS outpatient 91 68.25 AETNA MCR ADV AETNA MCR ADV 70.98 78 999999999 70.98 86.45 percent of total billed charges HEMOGLOBIN; GLYCOSYLATED (A1C) 3018303601_1 CDM 301 RC 83036 HCPCS outpatient 91 68.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 79.69 87.57 999999999 70.98 86.45 percent of total billed charges HEMOGLOBIN; GLYCOSYLATED (A1C) 3018303601_1 CDM 301 RC 83036 HCPCS outpatient 91 68.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 77.41 85.07 999999999 70.98 86.45 percent of total billed charges HEMOGLOBIN; GLYCOSYLATED (A1C) 3018303601_1 CDM 301 RC 83036 HCPCS outpatient 91 68.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 77.41 85.07 999999999 70.98 86.45 percent of total billed charges HEMOGLOBIN; GLYCOSYLATED (A1C) 3018303601_1 CDM 301 RC 83036 HCPCS outpatient 91 68.25 MOLINA MCAID MOLINA MCAID 75.89 83.4 999999999 70.98 86.45 percent of total billed charges HEMOGLOBIN; GLYCOSYLATED (A1C) 3018303601_1 CDM 301 RC 83036 HCPCS outpatient 91 68.25 MOLINA MCR ADV MOLINA MCR ADV 80.99 89 999999999 70.98 86.45 percent of total billed charges HEMOGLOBIN; GLYCOSYLATED (A1C) 3018303601_1 CDM 301 RC 83036 HCPCS outpatient 91 68.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 80.99 89 999999999 70.98 86.45 percent of total billed charges HEMOGLOBIN; GLYCOSYLATED (A1C) 3018303601_1 CDM 301 RC 83036 HCPCS outpatient 91 68.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 80.99 89 999999999 70.98 86.45 percent of total billed charges HEMOGLOBIN; GLYCOSYLATED (A1C) 3018303601_1 CDM 301 RC 83036 HCPCS outpatient 91 68.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 81.9 90 999999999 70.98 86.45 percent of total billed charges HEMOGLOBIN; GLYCOSYLATED (A1C) 3018303601_1 CDM 301 RC 83036 HCPCS outpatient 91 68.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 86.45 95 999999999 70.98 86.45 percent of total billed charges HEMOGLOBIN; GLYCOSYLATED (A1C) 3018303601_1 CDM 301 RC 83036 HCPCS outpatient 91 68.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 86.45 95 999999999 70.98 86.45 percent of total billed charges HEMOGLOBIN; GLYCOSYLATED (A1C) 3018303601_1 CDM 301 RC 83036 HCPCS outpatient 91 68.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 80.99 89 999999999 70.98 86.45 percent of total billed charges HEMOGLOBIN; GLYCOSYLATED (A1C) 3018303601_1 CDM 301 RC 83036 HCPCS outpatient 91 68.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 80.08 88 999999999 70.98 86.45 percent of total billed charges HEMOGLOBIN; GLYCOSYLATED (A1C) 3018303601_1 CDM 301 RC 83036 HCPCS outpatient 91 68.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 80.99 89 999999999 70.98 86.45 percent of total billed charges "HYDROXYINDOLACETIC ACID, 5-(HIAA)" 3018349702_1 CDM 301 RC 83497 HCPCS outpatient 118 88.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 106.2 90 999999999 92.04 112.1 percent of total billed charges "HYDROXYINDOLACETIC ACID, 5-(HIAA)" 3018349702_1 CDM 301 RC 83497 HCPCS outpatient 118 88.5 AETNA MCR ADV AETNA MCR ADV 92.04 78 999999999 92.04 112.1 percent of total billed charges "HYDROXYINDOLACETIC ACID, 5-(HIAA)" 3018349702_1 CDM 301 RC 83497 HCPCS outpatient 118 88.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 103.33 87.57 999999999 92.04 112.1 percent of total billed charges "HYDROXYINDOLACETIC ACID, 5-(HIAA)" 3018349702_1 CDM 301 RC 83497 HCPCS outpatient 118 88.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 100.38 85.07 999999999 92.04 112.1 percent of total billed charges "HYDROXYINDOLACETIC ACID, 5-(HIAA)" 3018349702_1 CDM 301 RC 83497 HCPCS outpatient 118 88.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 100.38 85.07 999999999 92.04 112.1 percent of total billed charges "HYDROXYINDOLACETIC ACID, 5-(HIAA)" 3018349702_1 CDM 301 RC 83497 HCPCS outpatient 118 88.5 MOLINA MCAID MOLINA MCAID 98.41 83.4 999999999 92.04 112.1 percent of total billed charges "HYDROXYINDOLACETIC ACID, 5-(HIAA)" 3018349702_1 CDM 301 RC 83497 HCPCS outpatient 118 88.5 MOLINA MCR ADV MOLINA MCR ADV 105.02 89 999999999 92.04 112.1 percent of total billed charges "HYDROXYINDOLACETIC ACID, 5-(HIAA)" 3018349702_1 CDM 301 RC 83497 HCPCS outpatient 118 88.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 105.02 89 999999999 92.04 112.1 percent of total billed charges "HYDROXYINDOLACETIC ACID, 5-(HIAA)" 3018349702_1 CDM 301 RC 83497 HCPCS outpatient 118 88.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 105.02 89 999999999 92.04 112.1 percent of total billed charges "HYDROXYINDOLACETIC ACID, 5-(HIAA)" 3018349702_1 CDM 301 RC 83497 HCPCS outpatient 118 88.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 106.2 90 999999999 92.04 112.1 percent of total billed charges "HYDROXYINDOLACETIC ACID, 5-(HIAA)" 3018349702_1 CDM 301 RC 83497 HCPCS outpatient 118 88.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 112.1 95 999999999 92.04 112.1 percent of total billed charges "HYDROXYINDOLACETIC ACID, 5-(HIAA)" 3018349702_1 CDM 301 RC 83497 HCPCS outpatient 118 88.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 112.1 95 999999999 92.04 112.1 percent of total billed charges "HYDROXYINDOLACETIC ACID, 5-(HIAA)" 3018349702_1 CDM 301 RC 83497 HCPCS outpatient 118 88.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 105.02 89 999999999 92.04 112.1 percent of total billed charges "HYDROXYINDOLACETIC ACID, 5-(HIAA)" 3018349702_1 CDM 301 RC 83497 HCPCS outpatient 118 88.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 103.84 88 999999999 92.04 112.1 percent of total billed charges "HYDROXYINDOLACETIC ACID, 5-(HIAA)" 3018349702_1 CDM 301 RC 83497 HCPCS outpatient 118 88.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 105.02 89 999999999 92.04 112.1 percent of total billed charges "HYDROXYPROGESTERONE, 17-D" 3018349801_1 CDM 301 RC 83498 HCPCS outpatient 140 105 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 126 90 999999999 109.2 133 percent of total billed charges "HYDROXYPROGESTERONE, 17-D" 3018349801_1 CDM 301 RC 83498 HCPCS outpatient 140 105 AETNA MCR ADV AETNA MCR ADV 109.2 78 999999999 109.2 133 percent of total billed charges "HYDROXYPROGESTERONE, 17-D" 3018349801_1 CDM 301 RC 83498 HCPCS outpatient 140 105 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 122.6 87.57 999999999 109.2 133 percent of total billed charges "HYDROXYPROGESTERONE, 17-D" 3018349801_1 CDM 301 RC 83498 HCPCS outpatient 140 105 COORDINATED CARE MCAID COORDINATED CARE MCAID 119.1 85.07 999999999 109.2 133 percent of total billed charges "HYDROXYPROGESTERONE, 17-D" 3018349801_1 CDM 301 RC 83498 HCPCS outpatient 140 105 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 119.1 85.07 999999999 109.2 133 percent of total billed charges "HYDROXYPROGESTERONE, 17-D" 3018349801_1 CDM 301 RC 83498 HCPCS outpatient 140 105 MOLINA MCAID MOLINA MCAID 116.76 83.4 999999999 109.2 133 percent of total billed charges "HYDROXYPROGESTERONE, 17-D" 3018349801_1 CDM 301 RC 83498 HCPCS outpatient 140 105 MOLINA MCR ADV MOLINA MCR ADV 124.6 89 999999999 109.2 133 percent of total billed charges "HYDROXYPROGESTERONE, 17-D" 3018349801_1 CDM 301 RC 83498 HCPCS outpatient 140 105 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 124.6 89 999999999 109.2 133 percent of total billed charges "HYDROXYPROGESTERONE, 17-D" 3018349801_1 CDM 301 RC 83498 HCPCS outpatient 140 105 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 124.6 89 999999999 109.2 133 percent of total billed charges "HYDROXYPROGESTERONE, 17-D" 3018349801_1 CDM 301 RC 83498 HCPCS outpatient 140 105 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 126 90 999999999 109.2 133 percent of total billed charges "HYDROXYPROGESTERONE, 17-D" 3018349801_1 CDM 301 RC 83498 HCPCS outpatient 140 105 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 133 95 999999999 109.2 133 percent of total billed charges "HYDROXYPROGESTERONE, 17-D" 3018349801_1 CDM 301 RC 83498 HCPCS outpatient 140 105 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 133 95 999999999 109.2 133 percent of total billed charges "HYDROXYPROGESTERONE, 17-D" 3018349801_1 CDM 301 RC 83498 HCPCS outpatient 140 105 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 124.6 89 999999999 109.2 133 percent of total billed charges "HYDROXYPROGESTERONE, 17-D" 3018349801_1 CDM 301 RC 83498 HCPCS outpatient 140 105 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 123.2 88 999999999 109.2 133 percent of total billed charges "HYDROXYPROGESTERONE, 17-D" 3018349801_1 CDM 301 RC 83498 HCPCS outpatient 140 105 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 124.6 89 999999999 109.2 133 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP METHOD" 3018351606_1 CDM 301 RC 83516 HCPCS outpatient 138 103.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 124.2 90 999999999 107.64 131.1 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP METHOD" 3018351606_1 CDM 301 RC 83516 HCPCS outpatient 138 103.5 AETNA MCR ADV AETNA MCR ADV 107.64 78 999999999 107.64 131.1 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP METHOD" 3018351606_1 CDM 301 RC 83516 HCPCS outpatient 138 103.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 120.85 87.57 999999999 107.64 131.1 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP METHOD" 3018351606_1 CDM 301 RC 83516 HCPCS outpatient 138 103.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 117.4 85.07 999999999 107.64 131.1 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP METHOD" 3018351606_1 CDM 301 RC 83516 HCPCS outpatient 138 103.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 117.4 85.07 999999999 107.64 131.1 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP METHOD" 3018351606_1 CDM 301 RC 83516 HCPCS outpatient 138 103.5 MOLINA MCAID MOLINA MCAID 115.09 83.4 999999999 107.64 131.1 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP METHOD" 3018351606_1 CDM 301 RC 83516 HCPCS outpatient 138 103.5 MOLINA MCR ADV MOLINA MCR ADV 122.82 89 999999999 107.64 131.1 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP METHOD" 3018351606_1 CDM 301 RC 83516 HCPCS outpatient 138 103.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 122.82 89 999999999 107.64 131.1 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP METHOD" 3018351606_1 CDM 301 RC 83516 HCPCS outpatient 138 103.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 122.82 89 999999999 107.64 131.1 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP METHOD" 3018351606_1 CDM 301 RC 83516 HCPCS outpatient 138 103.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 124.2 90 999999999 107.64 131.1 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP METHOD" 3018351606_1 CDM 301 RC 83516 HCPCS outpatient 138 103.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 131.1 95 999999999 107.64 131.1 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP METHOD" 3018351606_1 CDM 301 RC 83516 HCPCS outpatient 138 103.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 131.1 95 999999999 107.64 131.1 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP METHOD" 3018351606_1 CDM 301 RC 83516 HCPCS outpatient 138 103.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 122.82 89 999999999 107.64 131.1 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP METHOD" 3018351606_1 CDM 301 RC 83516 HCPCS outpatient 138 103.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 121.44 88 999999999 107.64 131.1 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP METHOD" 3018351606_1 CDM 301 RC 83516 HCPCS outpatient 138 103.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 122.82 89 999999999 107.64 131.1 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP METHOD" 3018351607_1 CDM 301 RC 83516 HCPCS outpatient 138 103.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 124.2 90 999999999 107.64 131.1 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP METHOD" 3018351607_1 CDM 301 RC 83516 HCPCS outpatient 138 103.5 AETNA MCR ADV AETNA MCR ADV 107.64 78 999999999 107.64 131.1 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP METHOD" 3018351607_1 CDM 301 RC 83516 HCPCS outpatient 138 103.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 120.85 87.57 999999999 107.64 131.1 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP METHOD" 3018351607_1 CDM 301 RC 83516 HCPCS outpatient 138 103.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 117.4 85.07 999999999 107.64 131.1 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP METHOD" 3018351607_1 CDM 301 RC 83516 HCPCS outpatient 138 103.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 117.4 85.07 999999999 107.64 131.1 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP METHOD" 3018351607_1 CDM 301 RC 83516 HCPCS outpatient 138 103.5 MOLINA MCAID MOLINA MCAID 115.09 83.4 999999999 107.64 131.1 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP METHOD" 3018351607_1 CDM 301 RC 83516 HCPCS outpatient 138 103.5 MOLINA MCR ADV MOLINA MCR ADV 122.82 89 999999999 107.64 131.1 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP METHOD" 3018351607_1 CDM 301 RC 83516 HCPCS outpatient 138 103.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 122.82 89 999999999 107.64 131.1 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP METHOD" 3018351607_1 CDM 301 RC 83516 HCPCS outpatient 138 103.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 122.82 89 999999999 107.64 131.1 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP METHOD" 3018351607_1 CDM 301 RC 83516 HCPCS outpatient 138 103.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 124.2 90 999999999 107.64 131.1 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP METHOD" 3018351607_1 CDM 301 RC 83516 HCPCS outpatient 138 103.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 131.1 95 999999999 107.64 131.1 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP METHOD" 3018351607_1 CDM 301 RC 83516 HCPCS outpatient 138 103.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 131.1 95 999999999 107.64 131.1 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP METHOD" 3018351607_1 CDM 301 RC 83516 HCPCS outpatient 138 103.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 122.82 89 999999999 107.64 131.1 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP METHOD" 3018351607_1 CDM 301 RC 83516 HCPCS outpatient 138 103.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 121.44 88 999999999 107.64 131.1 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP METHOD" 3018351607_1 CDM 301 RC 83516 HCPCS outpatient 138 103.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 122.82 89 999999999 107.64 131.1 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUANTITATIVE, BY RADIOIMMUNOASSAY (EG, RIA)" 3018351901_1 CDM 301 RC 83519 HCPCS outpatient 215 161.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 193.5 90 999999999 167.7 204.25 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUANTITATIVE, BY RADIOIMMUNOASSAY (EG, RIA)" 3018351901_1 CDM 301 RC 83519 HCPCS outpatient 215 161.25 AETNA MCR ADV AETNA MCR ADV 167.7 78 999999999 167.7 204.25 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUANTITATIVE, BY RADIOIMMUNOASSAY (EG, RIA)" 3018351901_1 CDM 301 RC 83519 HCPCS outpatient 215 161.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 188.28 87.57 999999999 167.7 204.25 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUANTITATIVE, BY RADIOIMMUNOASSAY (EG, RIA)" 3018351901_1 CDM 301 RC 83519 HCPCS outpatient 215 161.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 182.9 85.07 999999999 167.7 204.25 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUANTITATIVE, BY RADIOIMMUNOASSAY (EG, RIA)" 3018351901_1 CDM 301 RC 83519 HCPCS outpatient 215 161.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 182.9 85.07 999999999 167.7 204.25 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUANTITATIVE, BY RADIOIMMUNOASSAY (EG, RIA)" 3018351901_1 CDM 301 RC 83519 HCPCS outpatient 215 161.25 MOLINA MCAID MOLINA MCAID 179.31 83.4 999999999 167.7 204.25 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUANTITATIVE, BY RADIOIMMUNOASSAY (EG, RIA)" 3018351901_1 CDM 301 RC 83519 HCPCS outpatient 215 161.25 MOLINA MCR ADV MOLINA MCR ADV 191.35 89 999999999 167.7 204.25 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUANTITATIVE, BY RADIOIMMUNOASSAY (EG, RIA)" 3018351901_1 CDM 301 RC 83519 HCPCS outpatient 215 161.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 191.35 89 999999999 167.7 204.25 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUANTITATIVE, BY RADIOIMMUNOASSAY (EG, RIA)" 3018351901_1 CDM 301 RC 83519 HCPCS outpatient 215 161.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 191.35 89 999999999 167.7 204.25 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUANTITATIVE, BY RADIOIMMUNOASSAY (EG, RIA)" 3018351901_1 CDM 301 RC 83519 HCPCS outpatient 215 161.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 193.5 90 999999999 167.7 204.25 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUANTITATIVE, BY RADIOIMMUNOASSAY (EG, RIA)" 3018351901_1 CDM 301 RC 83519 HCPCS outpatient 215 161.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 204.25 95 999999999 167.7 204.25 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUANTITATIVE, BY RADIOIMMUNOASSAY (EG, RIA)" 3018351901_1 CDM 301 RC 83519 HCPCS outpatient 215 161.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 204.25 95 999999999 167.7 204.25 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUANTITATIVE, BY RADIOIMMUNOASSAY (EG, RIA)" 3018351901_1 CDM 301 RC 83519 HCPCS outpatient 215 161.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 191.35 89 999999999 167.7 204.25 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUANTITATIVE, BY RADIOIMMUNOASSAY (EG, RIA)" 3018351901_1 CDM 301 RC 83519 HCPCS outpatient 215 161.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 189.2 88 999999999 167.7 204.25 percent of total billed charges "IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUANTITATIVE, BY RADIOIMMUNOASSAY (EG, RIA)" 3018351901_1 CDM 301 RC 83519 HCPCS outpatient 215 161.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 191.35 89 999999999 167.7 204.25 percent of total billed charges INSULIN; TOTAL 3018352504_1 CDM 301 RC 83525 HCPCS outpatient 124 93 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 111.6 90 999999999 96.72 117.8 percent of total billed charges INSULIN; TOTAL 3018352504_1 CDM 301 RC 83525 HCPCS outpatient 124 93 AETNA MCR ADV AETNA MCR ADV 96.72 78 999999999 96.72 117.8 percent of total billed charges INSULIN; TOTAL 3018352504_1 CDM 301 RC 83525 HCPCS outpatient 124 93 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 108.59 87.57 999999999 96.72 117.8 percent of total billed charges INSULIN; TOTAL 3018352504_1 CDM 301 RC 83525 HCPCS outpatient 124 93 COORDINATED CARE MCAID COORDINATED CARE MCAID 105.49 85.07 999999999 96.72 117.8 percent of total billed charges INSULIN; TOTAL 3018352504_1 CDM 301 RC 83525 HCPCS outpatient 124 93 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 105.49 85.07 999999999 96.72 117.8 percent of total billed charges INSULIN; TOTAL 3018352504_1 CDM 301 RC 83525 HCPCS outpatient 124 93 MOLINA MCAID MOLINA MCAID 103.42 83.4 999999999 96.72 117.8 percent of total billed charges INSULIN; TOTAL 3018352504_1 CDM 301 RC 83525 HCPCS outpatient 124 93 MOLINA MCR ADV MOLINA MCR ADV 110.36 89 999999999 96.72 117.8 percent of total billed charges INSULIN; TOTAL 3018352504_1 CDM 301 RC 83525 HCPCS outpatient 124 93 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 110.36 89 999999999 96.72 117.8 percent of total billed charges INSULIN; TOTAL 3018352504_1 CDM 301 RC 83525 HCPCS outpatient 124 93 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 110.36 89 999999999 96.72 117.8 percent of total billed charges INSULIN; TOTAL 3018352504_1 CDM 301 RC 83525 HCPCS outpatient 124 93 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 111.6 90 999999999 96.72 117.8 percent of total billed charges INSULIN; TOTAL 3018352504_1 CDM 301 RC 83525 HCPCS outpatient 124 93 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 117.8 95 999999999 96.72 117.8 percent of total billed charges INSULIN; TOTAL 3018352504_1 CDM 301 RC 83525 HCPCS outpatient 124 93 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 117.8 95 999999999 96.72 117.8 percent of total billed charges INSULIN; TOTAL 3018352504_1 CDM 301 RC 83525 HCPCS outpatient 124 93 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 110.36 89 999999999 96.72 117.8 percent of total billed charges INSULIN; TOTAL 3018352504_1 CDM 301 RC 83525 HCPCS outpatient 124 93 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 109.12 88 999999999 96.72 117.8 percent of total billed charges INSULIN; TOTAL 3018352504_1 CDM 301 RC 83525 HCPCS outpatient 124 93 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 110.36 89 999999999 96.72 117.8 percent of total billed charges IRON 3018354001_1 CDM 301 RC 83540 HCPCS outpatient 69 51.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 62.1 90 999999999 53.82 65.55 percent of total billed charges IRON 3018354001_1 CDM 301 RC 83540 HCPCS outpatient 69 51.75 AETNA MCR ADV AETNA MCR ADV 53.82 78 999999999 53.82 65.55 percent of total billed charges IRON 3018354001_1 CDM 301 RC 83540 HCPCS outpatient 69 51.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 60.42 87.57 999999999 53.82 65.55 percent of total billed charges IRON 3018354001_1 CDM 301 RC 83540 HCPCS outpatient 69 51.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 58.7 85.07 999999999 53.82 65.55 percent of total billed charges IRON 3018354001_1 CDM 301 RC 83540 HCPCS outpatient 69 51.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 58.7 85.07 999999999 53.82 65.55 percent of total billed charges IRON 3018354001_1 CDM 301 RC 83540 HCPCS outpatient 69 51.75 MOLINA MCAID MOLINA MCAID 57.55 83.4 999999999 53.82 65.55 percent of total billed charges IRON 3018354001_1 CDM 301 RC 83540 HCPCS outpatient 69 51.75 MOLINA MCR ADV MOLINA MCR ADV 61.41 89 999999999 53.82 65.55 percent of total billed charges IRON 3018354001_1 CDM 301 RC 83540 HCPCS outpatient 69 51.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 61.41 89 999999999 53.82 65.55 percent of total billed charges IRON 3018354001_1 CDM 301 RC 83540 HCPCS outpatient 69 51.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 61.41 89 999999999 53.82 65.55 percent of total billed charges IRON 3018354001_1 CDM 301 RC 83540 HCPCS outpatient 69 51.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 62.1 90 999999999 53.82 65.55 percent of total billed charges IRON 3018354001_1 CDM 301 RC 83540 HCPCS outpatient 69 51.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 65.55 95 999999999 53.82 65.55 percent of total billed charges IRON 3018354001_1 CDM 301 RC 83540 HCPCS outpatient 69 51.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 65.55 95 999999999 53.82 65.55 percent of total billed charges IRON 3018354001_1 CDM 301 RC 83540 HCPCS outpatient 69 51.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 61.41 89 999999999 53.82 65.55 percent of total billed charges IRON 3018354001_1 CDM 301 RC 83540 HCPCS outpatient 69 51.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 60.72 88 999999999 53.82 65.55 percent of total billed charges IRON 3018354001_1 CDM 301 RC 83540 HCPCS outpatient 69 51.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 61.41 89 999999999 53.82 65.55 percent of total billed charges IRON BINDING CAPACITY 3018355001_1 CDM 301 RC 83550 HCPCS outpatient 67 50.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 60.3 90 999999999 52.26 63.65 percent of total billed charges IRON BINDING CAPACITY 3018355001_1 CDM 301 RC 83550 HCPCS outpatient 67 50.25 AETNA MCR ADV AETNA MCR ADV 52.26 78 999999999 52.26 63.65 percent of total billed charges IRON BINDING CAPACITY 3018355001_1 CDM 301 RC 83550 HCPCS outpatient 67 50.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 58.67 87.57 999999999 52.26 63.65 percent of total billed charges IRON BINDING CAPACITY 3018355001_1 CDM 301 RC 83550 HCPCS outpatient 67 50.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 57 85.07 999999999 52.26 63.65 percent of total billed charges IRON BINDING CAPACITY 3018355001_1 CDM 301 RC 83550 HCPCS outpatient 67 50.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 57 85.07 999999999 52.26 63.65 percent of total billed charges IRON BINDING CAPACITY 3018355001_1 CDM 301 RC 83550 HCPCS outpatient 67 50.25 MOLINA MCAID MOLINA MCAID 55.88 83.4 999999999 52.26 63.65 percent of total billed charges IRON BINDING CAPACITY 3018355001_1 CDM 301 RC 83550 HCPCS outpatient 67 50.25 MOLINA MCR ADV MOLINA MCR ADV 59.63 89 999999999 52.26 63.65 percent of total billed charges IRON BINDING CAPACITY 3018355001_1 CDM 301 RC 83550 HCPCS outpatient 67 50.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 59.63 89 999999999 52.26 63.65 percent of total billed charges IRON BINDING CAPACITY 3018355001_1 CDM 301 RC 83550 HCPCS outpatient 67 50.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 59.63 89 999999999 52.26 63.65 percent of total billed charges IRON BINDING CAPACITY 3018355001_1 CDM 301 RC 83550 HCPCS outpatient 67 50.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 60.3 90 999999999 52.26 63.65 percent of total billed charges IRON BINDING CAPACITY 3018355001_1 CDM 301 RC 83550 HCPCS outpatient 67 50.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 63.65 95 999999999 52.26 63.65 percent of total billed charges IRON BINDING CAPACITY 3018355001_1 CDM 301 RC 83550 HCPCS outpatient 67 50.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 63.65 95 999999999 52.26 63.65 percent of total billed charges IRON BINDING CAPACITY 3018355001_1 CDM 301 RC 83550 HCPCS outpatient 67 50.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 59.63 89 999999999 52.26 63.65 percent of total billed charges IRON BINDING CAPACITY 3018355001_1 CDM 301 RC 83550 HCPCS outpatient 67 50.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 58.96 88 999999999 52.26 63.65 percent of total billed charges IRON BINDING CAPACITY 3018355001_1 CDM 301 RC 83550 HCPCS outpatient 67 50.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 59.63 89 999999999 52.26 63.65 percent of total billed charges LACTATE (LACTIC ACID) 3018360501_1 CDM 301 RC 83605 HCPCS outpatient 150 112.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 135 90 999999999 117 142.5 percent of total billed charges LACTATE (LACTIC ACID) 3018360501_1 CDM 301 RC 83605 HCPCS outpatient 150 112.5 AETNA MCR ADV AETNA MCR ADV 117 78 999999999 117 142.5 percent of total billed charges LACTATE (LACTIC ACID) 3018360501_1 CDM 301 RC 83605 HCPCS outpatient 150 112.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 131.36 87.57 999999999 117 142.5 percent of total billed charges LACTATE (LACTIC ACID) 3018360501_1 CDM 301 RC 83605 HCPCS outpatient 150 112.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 127.61 85.07 999999999 117 142.5 percent of total billed charges LACTATE (LACTIC ACID) 3018360501_1 CDM 301 RC 83605 HCPCS outpatient 150 112.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 127.61 85.07 999999999 117 142.5 percent of total billed charges LACTATE (LACTIC ACID) 3018360501_1 CDM 301 RC 83605 HCPCS outpatient 150 112.5 MOLINA MCAID MOLINA MCAID 125.1 83.4 999999999 117 142.5 percent of total billed charges LACTATE (LACTIC ACID) 3018360501_1 CDM 301 RC 83605 HCPCS outpatient 150 112.5 MOLINA MCR ADV MOLINA MCR ADV 133.5 89 999999999 117 142.5 percent of total billed charges LACTATE (LACTIC ACID) 3018360501_1 CDM 301 RC 83605 HCPCS outpatient 150 112.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 133.5 89 999999999 117 142.5 percent of total billed charges LACTATE (LACTIC ACID) 3018360501_1 CDM 301 RC 83605 HCPCS outpatient 150 112.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 133.5 89 999999999 117 142.5 percent of total billed charges LACTATE (LACTIC ACID) 3018360501_1 CDM 301 RC 83605 HCPCS outpatient 150 112.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 135 90 999999999 117 142.5 percent of total billed charges LACTATE (LACTIC ACID) 3018360501_1 CDM 301 RC 83605 HCPCS outpatient 150 112.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 142.5 95 999999999 117 142.5 percent of total billed charges LACTATE (LACTIC ACID) 3018360501_1 CDM 301 RC 83605 HCPCS outpatient 150 112.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 142.5 95 999999999 117 142.5 percent of total billed charges LACTATE (LACTIC ACID) 3018360501_1 CDM 301 RC 83605 HCPCS outpatient 150 112.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 133.5 89 999999999 117 142.5 percent of total billed charges LACTATE (LACTIC ACID) 3018360501_1 CDM 301 RC 83605 HCPCS outpatient 150 112.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 132 88 999999999 117 142.5 percent of total billed charges LACTATE (LACTIC ACID) 3018360501_1 CDM 301 RC 83605 HCPCS outpatient 150 112.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 133.5 89 999999999 117 142.5 percent of total billed charges "LACTATE DEHYDROGENASE (LD), (LDH)" 3018361501_1 CDM 301 RC 83615 HCPCS outpatient 74 55.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 66.6 90 999999999 57.72 70.3 percent of total billed charges "LACTATE DEHYDROGENASE (LD), (LDH)" 3018361501_1 CDM 301 RC 83615 HCPCS outpatient 74 55.5 AETNA MCR ADV AETNA MCR ADV 57.72 78 999999999 57.72 70.3 percent of total billed charges "LACTATE DEHYDROGENASE (LD), (LDH)" 3018361501_1 CDM 301 RC 83615 HCPCS outpatient 74 55.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 64.8 87.57 999999999 57.72 70.3 percent of total billed charges "LACTATE DEHYDROGENASE (LD), (LDH)" 3018361501_1 CDM 301 RC 83615 HCPCS outpatient 74 55.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 62.95 85.07 999999999 57.72 70.3 percent of total billed charges "LACTATE DEHYDROGENASE (LD), (LDH)" 3018361501_1 CDM 301 RC 83615 HCPCS outpatient 74 55.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 62.95 85.07 999999999 57.72 70.3 percent of total billed charges "LACTATE DEHYDROGENASE (LD), (LDH)" 3018361501_1 CDM 301 RC 83615 HCPCS outpatient 74 55.5 MOLINA MCAID MOLINA MCAID 61.72 83.4 999999999 57.72 70.3 percent of total billed charges "LACTATE DEHYDROGENASE (LD), (LDH)" 3018361501_1 CDM 301 RC 83615 HCPCS outpatient 74 55.5 MOLINA MCR ADV MOLINA MCR ADV 65.86 89 999999999 57.72 70.3 percent of total billed charges "LACTATE DEHYDROGENASE (LD), (LDH)" 3018361501_1 CDM 301 RC 83615 HCPCS outpatient 74 55.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 65.86 89 999999999 57.72 70.3 percent of total billed charges "LACTATE DEHYDROGENASE (LD), (LDH)" 3018361501_1 CDM 301 RC 83615 HCPCS outpatient 74 55.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 65.86 89 999999999 57.72 70.3 percent of total billed charges "LACTATE DEHYDROGENASE (LD), (LDH)" 3018361501_1 CDM 301 RC 83615 HCPCS outpatient 74 55.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 66.6 90 999999999 57.72 70.3 percent of total billed charges "LACTATE DEHYDROGENASE (LD), (LDH)" 3018361501_1 CDM 301 RC 83615 HCPCS outpatient 74 55.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 70.3 95 999999999 57.72 70.3 percent of total billed charges "LACTATE DEHYDROGENASE (LD), (LDH)" 3018361501_1 CDM 301 RC 83615 HCPCS outpatient 74 55.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 70.3 95 999999999 57.72 70.3 percent of total billed charges "LACTATE DEHYDROGENASE (LD), (LDH)" 3018361501_1 CDM 301 RC 83615 HCPCS outpatient 74 55.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 65.86 89 999999999 57.72 70.3 percent of total billed charges "LACTATE DEHYDROGENASE (LD), (LDH)" 3018361501_1 CDM 301 RC 83615 HCPCS outpatient 74 55.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 65.12 88 999999999 57.72 70.3 percent of total billed charges "LACTATE DEHYDROGENASE (LD), (LDH)" 3018361501_1 CDM 301 RC 83615 HCPCS outpatient 74 55.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 65.86 89 999999999 57.72 70.3 percent of total billed charges "LACTATE DEHYDROGENASE (LD), (LDH); ISOENZYMES, SEPARATION AND QUANTITATION" 3018362501_1 CDM 301 RC 83625 HCPCS outpatient 134 100.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 120.6 90 999999999 104.52 127.3 percent of total billed charges "LACTATE DEHYDROGENASE (LD), (LDH); ISOENZYMES, SEPARATION AND QUANTITATION" 3018362501_1 CDM 301 RC 83625 HCPCS outpatient 134 100.5 AETNA MCR ADV AETNA MCR ADV 104.52 78 999999999 104.52 127.3 percent of total billed charges "LACTATE DEHYDROGENASE (LD), (LDH); ISOENZYMES, SEPARATION AND QUANTITATION" 3018362501_1 CDM 301 RC 83625 HCPCS outpatient 134 100.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 117.34 87.57 999999999 104.52 127.3 percent of total billed charges "LACTATE DEHYDROGENASE (LD), (LDH); ISOENZYMES, SEPARATION AND QUANTITATION" 3018362501_1 CDM 301 RC 83625 HCPCS outpatient 134 100.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 113.99 85.07 999999999 104.52 127.3 percent of total billed charges "LACTATE DEHYDROGENASE (LD), (LDH); ISOENZYMES, SEPARATION AND QUANTITATION" 3018362501_1 CDM 301 RC 83625 HCPCS outpatient 134 100.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 113.99 85.07 999999999 104.52 127.3 percent of total billed charges "LACTATE DEHYDROGENASE (LD), (LDH); ISOENZYMES, SEPARATION AND QUANTITATION" 3018362501_1 CDM 301 RC 83625 HCPCS outpatient 134 100.5 MOLINA MCAID MOLINA MCAID 111.76 83.4 999999999 104.52 127.3 percent of total billed charges "LACTATE DEHYDROGENASE (LD), (LDH); ISOENZYMES, SEPARATION AND QUANTITATION" 3018362501_1 CDM 301 RC 83625 HCPCS outpatient 134 100.5 MOLINA MCR ADV MOLINA MCR ADV 119.26 89 999999999 104.52 127.3 percent of total billed charges "LACTATE DEHYDROGENASE (LD), (LDH); ISOENZYMES, SEPARATION AND QUANTITATION" 3018362501_1 CDM 301 RC 83625 HCPCS outpatient 134 100.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 119.26 89 999999999 104.52 127.3 percent of total billed charges "LACTATE DEHYDROGENASE (LD), (LDH); ISOENZYMES, SEPARATION AND QUANTITATION" 3018362501_1 CDM 301 RC 83625 HCPCS outpatient 134 100.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 119.26 89 999999999 104.52 127.3 percent of total billed charges "LACTATE DEHYDROGENASE (LD), (LDH); ISOENZYMES, SEPARATION AND QUANTITATION" 3018362501_1 CDM 301 RC 83625 HCPCS outpatient 134 100.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 120.6 90 999999999 104.52 127.3 percent of total billed charges "LACTATE DEHYDROGENASE (LD), (LDH); ISOENZYMES, SEPARATION AND QUANTITATION" 3018362501_1 CDM 301 RC 83625 HCPCS outpatient 134 100.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 127.3 95 999999999 104.52 127.3 percent of total billed charges "LACTATE DEHYDROGENASE (LD), (LDH); ISOENZYMES, SEPARATION AND QUANTITATION" 3018362501_1 CDM 301 RC 83625 HCPCS outpatient 134 100.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 127.3 95 999999999 104.52 127.3 percent of total billed charges "LACTATE DEHYDROGENASE (LD), (LDH); ISOENZYMES, SEPARATION AND QUANTITATION" 3018362501_1 CDM 301 RC 83625 HCPCS outpatient 134 100.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 119.26 89 999999999 104.52 127.3 percent of total billed charges "LACTATE DEHYDROGENASE (LD), (LDH); ISOENZYMES, SEPARATION AND QUANTITATION" 3018362501_1 CDM 301 RC 83625 HCPCS outpatient 134 100.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 117.92 88 999999999 104.52 127.3 percent of total billed charges "LACTATE DEHYDROGENASE (LD), (LDH); ISOENZYMES, SEPARATION AND QUANTITATION" 3018362501_1 CDM 301 RC 83625 HCPCS outpatient 134 100.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 119.26 89 999999999 104.52 127.3 percent of total billed charges "LACTOFERRIN, FECAL; QUALITATIVE" 3018363001_1 CDM 301 RC 83630 HCPCS outpatient 93 69.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 83.7 90 999999999 72.54 88.35 percent of total billed charges "LACTOFERRIN, FECAL; QUALITATIVE" 3018363001_1 CDM 301 RC 83630 HCPCS outpatient 93 69.75 AETNA MCR ADV AETNA MCR ADV 72.54 78 999999999 72.54 88.35 percent of total billed charges "LACTOFERRIN, FECAL; QUALITATIVE" 3018363001_1 CDM 301 RC 83630 HCPCS outpatient 93 69.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 81.44 87.57 999999999 72.54 88.35 percent of total billed charges "LACTOFERRIN, FECAL; QUALITATIVE" 3018363001_1 CDM 301 RC 83630 HCPCS outpatient 93 69.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 79.12 85.07 999999999 72.54 88.35 percent of total billed charges "LACTOFERRIN, FECAL; QUALITATIVE" 3018363001_1 CDM 301 RC 83630 HCPCS outpatient 93 69.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 79.12 85.07 999999999 72.54 88.35 percent of total billed charges "LACTOFERRIN, FECAL; QUALITATIVE" 3018363001_1 CDM 301 RC 83630 HCPCS outpatient 93 69.75 MOLINA MCAID MOLINA MCAID 77.56 83.4 999999999 72.54 88.35 percent of total billed charges "LACTOFERRIN, FECAL; QUALITATIVE" 3018363001_1 CDM 301 RC 83630 HCPCS outpatient 93 69.75 MOLINA MCR ADV MOLINA MCR ADV 82.77 89 999999999 72.54 88.35 percent of total billed charges "LACTOFERRIN, FECAL; QUALITATIVE" 3018363001_1 CDM 301 RC 83630 HCPCS outpatient 93 69.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 82.77 89 999999999 72.54 88.35 percent of total billed charges "LACTOFERRIN, FECAL; QUALITATIVE" 3018363001_1 CDM 301 RC 83630 HCPCS outpatient 93 69.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 82.77 89 999999999 72.54 88.35 percent of total billed charges "LACTOFERRIN, FECAL; QUALITATIVE" 3018363001_1 CDM 301 RC 83630 HCPCS outpatient 93 69.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 83.7 90 999999999 72.54 88.35 percent of total billed charges "LACTOFERRIN, FECAL; QUALITATIVE" 3018363001_1 CDM 301 RC 83630 HCPCS outpatient 93 69.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 88.35 95 999999999 72.54 88.35 percent of total billed charges "LACTOFERRIN, FECAL; QUALITATIVE" 3018363001_1 CDM 301 RC 83630 HCPCS outpatient 93 69.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 88.35 95 999999999 72.54 88.35 percent of total billed charges "LACTOFERRIN, FECAL; QUALITATIVE" 3018363001_1 CDM 301 RC 83630 HCPCS outpatient 93 69.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 82.77 89 999999999 72.54 88.35 percent of total billed charges "LACTOFERRIN, FECAL; QUALITATIVE" 3018363001_1 CDM 301 RC 83630 HCPCS outpatient 93 69.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 81.84 88 999999999 72.54 88.35 percent of total billed charges "LACTOFERRIN, FECAL; QUALITATIVE" 3018363001_1 CDM 301 RC 83630 HCPCS outpatient 93 69.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 82.77 89 999999999 72.54 88.35 percent of total billed charges LEAD 3018365505_1 CDM 301 RC 83655 HCPCS outpatient 89 66.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 80.1 90 999999999 69.42 84.55 percent of total billed charges LEAD 3018365505_1 CDM 301 RC 83655 HCPCS outpatient 89 66.75 AETNA MCR ADV AETNA MCR ADV 69.42 78 999999999 69.42 84.55 percent of total billed charges LEAD 3018365505_1 CDM 301 RC 83655 HCPCS outpatient 89 66.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 77.94 87.57 999999999 69.42 84.55 percent of total billed charges LEAD 3018365505_1 CDM 301 RC 83655 HCPCS outpatient 89 66.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 75.71 85.07 999999999 69.42 84.55 percent of total billed charges LEAD 3018365505_1 CDM 301 RC 83655 HCPCS outpatient 89 66.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 75.71 85.07 999999999 69.42 84.55 percent of total billed charges LEAD 3018365505_1 CDM 301 RC 83655 HCPCS outpatient 89 66.75 MOLINA MCAID MOLINA MCAID 74.23 83.4 999999999 69.42 84.55 percent of total billed charges LEAD 3018365505_1 CDM 301 RC 83655 HCPCS outpatient 89 66.75 MOLINA MCR ADV MOLINA MCR ADV 79.21 89 999999999 69.42 84.55 percent of total billed charges LEAD 3018365505_1 CDM 301 RC 83655 HCPCS outpatient 89 66.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 79.21 89 999999999 69.42 84.55 percent of total billed charges LEAD 3018365505_1 CDM 301 RC 83655 HCPCS outpatient 89 66.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 79.21 89 999999999 69.42 84.55 percent of total billed charges LEAD 3018365505_1 CDM 301 RC 83655 HCPCS outpatient 89 66.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 80.1 90 999999999 69.42 84.55 percent of total billed charges LEAD 3018365505_1 CDM 301 RC 83655 HCPCS outpatient 89 66.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 84.55 95 999999999 69.42 84.55 percent of total billed charges LEAD 3018365505_1 CDM 301 RC 83655 HCPCS outpatient 89 66.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 84.55 95 999999999 69.42 84.55 percent of total billed charges LEAD 3018365505_1 CDM 301 RC 83655 HCPCS outpatient 89 66.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 79.21 89 999999999 69.42 84.55 percent of total billed charges LEAD 3018365505_1 CDM 301 RC 83655 HCPCS outpatient 89 66.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 78.32 88 999999999 69.42 84.55 percent of total billed charges LEAD 3018365505_1 CDM 301 RC 83655 HCPCS outpatient 89 66.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 79.21 89 999999999 69.42 84.55 percent of total billed charges LIPASE 3018369001_1 CDM 301 RC 83690 HCPCS outpatient 120 90 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 108 90 999999999 93.6 114 percent of total billed charges LIPASE 3018369001_1 CDM 301 RC 83690 HCPCS outpatient 120 90 AETNA MCR ADV AETNA MCR ADV 93.6 78 999999999 93.6 114 percent of total billed charges LIPASE 3018369001_1 CDM 301 RC 83690 HCPCS outpatient 120 90 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 105.08 87.57 999999999 93.6 114 percent of total billed charges LIPASE 3018369001_1 CDM 301 RC 83690 HCPCS outpatient 120 90 COORDINATED CARE MCAID COORDINATED CARE MCAID 102.08 85.07 999999999 93.6 114 percent of total billed charges LIPASE 3018369001_1 CDM 301 RC 83690 HCPCS outpatient 120 90 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 102.08 85.07 999999999 93.6 114 percent of total billed charges LIPASE 3018369001_1 CDM 301 RC 83690 HCPCS outpatient 120 90 MOLINA MCAID MOLINA MCAID 100.08 83.4 999999999 93.6 114 percent of total billed charges LIPASE 3018369001_1 CDM 301 RC 83690 HCPCS outpatient 120 90 MOLINA MCR ADV MOLINA MCR ADV 106.8 89 999999999 93.6 114 percent of total billed charges LIPASE 3018369001_1 CDM 301 RC 83690 HCPCS outpatient 120 90 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 106.8 89 999999999 93.6 114 percent of total billed charges LIPASE 3018369001_1 CDM 301 RC 83690 HCPCS outpatient 120 90 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 106.8 89 999999999 93.6 114 percent of total billed charges LIPASE 3018369001_1 CDM 301 RC 83690 HCPCS outpatient 120 90 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 108 90 999999999 93.6 114 percent of total billed charges LIPASE 3018369001_1 CDM 301 RC 83690 HCPCS outpatient 120 90 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 114 95 999999999 93.6 114 percent of total billed charges LIPASE 3018369001_1 CDM 301 RC 83690 HCPCS outpatient 120 90 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 114 95 999999999 93.6 114 percent of total billed charges LIPASE 3018369001_1 CDM 301 RC 83690 HCPCS outpatient 120 90 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 106.8 89 999999999 93.6 114 percent of total billed charges LIPASE 3018369001_1 CDM 301 RC 83690 HCPCS outpatient 120 90 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 105.6 88 999999999 93.6 114 percent of total billed charges LIPASE 3018369001_1 CDM 301 RC 83690 HCPCS outpatient 120 90 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 106.8 89 999999999 93.6 114 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; HIGH DENSITY CHOLESTEROL (HDL CHOLESTEROL)" 3018371801_1 CDM 301 RC 83718 HCPCS outpatient 102 76.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 91.8 90 999999999 79.56 96.9 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; HIGH DENSITY CHOLESTEROL (HDL CHOLESTEROL)" 3018371801_1 CDM 301 RC 83718 HCPCS outpatient 102 76.5 AETNA MCR ADV AETNA MCR ADV 79.56 78 999999999 79.56 96.9 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; HIGH DENSITY CHOLESTEROL (HDL CHOLESTEROL)" 3018371801_1 CDM 301 RC 83718 HCPCS outpatient 102 76.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 89.32 87.57 999999999 79.56 96.9 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; HIGH DENSITY CHOLESTEROL (HDL CHOLESTEROL)" 3018371801_1 CDM 301 RC 83718 HCPCS outpatient 102 76.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 86.77 85.07 999999999 79.56 96.9 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; HIGH DENSITY CHOLESTEROL (HDL CHOLESTEROL)" 3018371801_1 CDM 301 RC 83718 HCPCS outpatient 102 76.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 86.77 85.07 999999999 79.56 96.9 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; HIGH DENSITY CHOLESTEROL (HDL CHOLESTEROL)" 3018371801_1 CDM 301 RC 83718 HCPCS outpatient 102 76.5 MOLINA MCAID MOLINA MCAID 85.07 83.4 999999999 79.56 96.9 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; HIGH DENSITY CHOLESTEROL (HDL CHOLESTEROL)" 3018371801_1 CDM 301 RC 83718 HCPCS outpatient 102 76.5 MOLINA MCR ADV MOLINA MCR ADV 90.78 89 999999999 79.56 96.9 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; HIGH DENSITY CHOLESTEROL (HDL CHOLESTEROL)" 3018371801_1 CDM 301 RC 83718 HCPCS outpatient 102 76.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 90.78 89 999999999 79.56 96.9 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; HIGH DENSITY CHOLESTEROL (HDL CHOLESTEROL)" 3018371801_1 CDM 301 RC 83718 HCPCS outpatient 102 76.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 90.78 89 999999999 79.56 96.9 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; HIGH DENSITY CHOLESTEROL (HDL CHOLESTEROL)" 3018371801_1 CDM 301 RC 83718 HCPCS outpatient 102 76.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 91.8 90 999999999 79.56 96.9 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; HIGH DENSITY CHOLESTEROL (HDL CHOLESTEROL)" 3018371801_1 CDM 301 RC 83718 HCPCS outpatient 102 76.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 96.9 95 999999999 79.56 96.9 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; HIGH DENSITY CHOLESTEROL (HDL CHOLESTEROL)" 3018371801_1 CDM 301 RC 83718 HCPCS outpatient 102 76.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 96.9 95 999999999 79.56 96.9 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; HIGH DENSITY CHOLESTEROL (HDL CHOLESTEROL)" 3018371801_1 CDM 301 RC 83718 HCPCS outpatient 102 76.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 90.78 89 999999999 79.56 96.9 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; HIGH DENSITY CHOLESTEROL (HDL CHOLESTEROL)" 3018371801_1 CDM 301 RC 83718 HCPCS outpatient 102 76.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 89.76 88 999999999 79.56 96.9 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; HIGH DENSITY CHOLESTEROL (HDL CHOLESTEROL)" 3018371801_1 CDM 301 RC 83718 HCPCS outpatient 102 76.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 90.78 89 999999999 79.56 96.9 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; LDL CHOLESTEROL" 3018372101_3 CDM 301 RC 83721 HCPCS outpatient 73 54.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 65.7 90 999999999 56.94 69.35 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; LDL CHOLESTEROL" 3018372101_3 CDM 301 RC 83721 HCPCS outpatient 73 54.75 AETNA MCR ADV AETNA MCR ADV 56.94 78 999999999 56.94 69.35 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; LDL CHOLESTEROL" 3018372101_3 CDM 301 RC 83721 HCPCS outpatient 73 54.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 63.93 87.57 999999999 56.94 69.35 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; LDL CHOLESTEROL" 3018372101_3 CDM 301 RC 83721 HCPCS outpatient 73 54.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 62.1 85.07 999999999 56.94 69.35 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; LDL CHOLESTEROL" 3018372101_3 CDM 301 RC 83721 HCPCS outpatient 73 54.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 62.1 85.07 999999999 56.94 69.35 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; LDL CHOLESTEROL" 3018372101_3 CDM 301 RC 83721 HCPCS outpatient 73 54.75 MOLINA MCAID MOLINA MCAID 60.88 83.4 999999999 56.94 69.35 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; LDL CHOLESTEROL" 3018372101_3 CDM 301 RC 83721 HCPCS outpatient 73 54.75 MOLINA MCR ADV MOLINA MCR ADV 64.97 89 999999999 56.94 69.35 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; LDL CHOLESTEROL" 3018372101_3 CDM 301 RC 83721 HCPCS outpatient 73 54.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 64.97 89 999999999 56.94 69.35 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; LDL CHOLESTEROL" 3018372101_3 CDM 301 RC 83721 HCPCS outpatient 73 54.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 64.97 89 999999999 56.94 69.35 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; LDL CHOLESTEROL" 3018372101_3 CDM 301 RC 83721 HCPCS outpatient 73 54.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 65.7 90 999999999 56.94 69.35 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; LDL CHOLESTEROL" 3018372101_3 CDM 301 RC 83721 HCPCS outpatient 73 54.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 69.35 95 999999999 56.94 69.35 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; LDL CHOLESTEROL" 3018372101_3 CDM 301 RC 83721 HCPCS outpatient 73 54.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 69.35 95 999999999 56.94 69.35 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; LDL CHOLESTEROL" 3018372101_3 CDM 301 RC 83721 HCPCS outpatient 73 54.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 64.97 89 999999999 56.94 69.35 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; LDL CHOLESTEROL" 3018372101_3 CDM 301 RC 83721 HCPCS outpatient 73 54.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 64.24 88 999999999 56.94 69.35 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; LDL CHOLESTEROL" 3018372101_3 CDM 301 RC 83721 HCPCS outpatient 73 54.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 64.97 89 999999999 56.94 69.35 percent of total billed charges MAGNESIUM 3018373501_1 CDM 301 RC 83735 HCPCS outpatient 78 58.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 70.2 90 999999999 60.84 74.1 percent of total billed charges MAGNESIUM 3018373501_1 CDM 301 RC 83735 HCPCS outpatient 78 58.5 AETNA MCR ADV AETNA MCR ADV 60.84 78 999999999 60.84 74.1 percent of total billed charges MAGNESIUM 3018373501_1 CDM 301 RC 83735 HCPCS outpatient 78 58.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 68.3 87.57 999999999 60.84 74.1 percent of total billed charges MAGNESIUM 3018373501_1 CDM 301 RC 83735 HCPCS outpatient 78 58.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 66.35 85.07 999999999 60.84 74.1 percent of total billed charges MAGNESIUM 3018373501_1 CDM 301 RC 83735 HCPCS outpatient 78 58.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 66.35 85.07 999999999 60.84 74.1 percent of total billed charges MAGNESIUM 3018373501_1 CDM 301 RC 83735 HCPCS outpatient 78 58.5 MOLINA MCAID MOLINA MCAID 65.05 83.4 999999999 60.84 74.1 percent of total billed charges MAGNESIUM 3018373501_1 CDM 301 RC 83735 HCPCS outpatient 78 58.5 MOLINA MCR ADV MOLINA MCR ADV 69.42 89 999999999 60.84 74.1 percent of total billed charges MAGNESIUM 3018373501_1 CDM 301 RC 83735 HCPCS outpatient 78 58.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 69.42 89 999999999 60.84 74.1 percent of total billed charges MAGNESIUM 3018373501_1 CDM 301 RC 83735 HCPCS outpatient 78 58.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 69.42 89 999999999 60.84 74.1 percent of total billed charges MAGNESIUM 3018373501_1 CDM 301 RC 83735 HCPCS outpatient 78 58.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 70.2 90 999999999 60.84 74.1 percent of total billed charges MAGNESIUM 3018373501_1 CDM 301 RC 83735 HCPCS outpatient 78 58.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 74.1 95 999999999 60.84 74.1 percent of total billed charges MAGNESIUM 3018373501_1 CDM 301 RC 83735 HCPCS outpatient 78 58.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 74.1 95 999999999 60.84 74.1 percent of total billed charges MAGNESIUM 3018373501_1 CDM 301 RC 83735 HCPCS outpatient 78 58.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 69.42 89 999999999 60.84 74.1 percent of total billed charges MAGNESIUM 3018373501_1 CDM 301 RC 83735 HCPCS outpatient 78 58.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 68.64 88 999999999 60.84 74.1 percent of total billed charges MAGNESIUM 3018373501_1 CDM 301 RC 83735 HCPCS outpatient 78 58.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 69.42 89 999999999 60.84 74.1 percent of total billed charges MYOGLOBIN 3018387401_1 CDM 301 RC 83874 HCPCS outpatient 159 119.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 143.1 90 999999999 124.02 151.05 percent of total billed charges MYOGLOBIN 3018387401_1 CDM 301 RC 83874 HCPCS outpatient 159 119.25 AETNA MCR ADV AETNA MCR ADV 124.02 78 999999999 124.02 151.05 percent of total billed charges MYOGLOBIN 3018387401_1 CDM 301 RC 83874 HCPCS outpatient 159 119.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 139.24 87.57 999999999 124.02 151.05 percent of total billed charges MYOGLOBIN 3018387401_1 CDM 301 RC 83874 HCPCS outpatient 159 119.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 135.26 85.07 999999999 124.02 151.05 percent of total billed charges MYOGLOBIN 3018387401_1 CDM 301 RC 83874 HCPCS outpatient 159 119.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 135.26 85.07 999999999 124.02 151.05 percent of total billed charges MYOGLOBIN 3018387401_1 CDM 301 RC 83874 HCPCS outpatient 159 119.25 MOLINA MCAID MOLINA MCAID 132.61 83.4 999999999 124.02 151.05 percent of total billed charges MYOGLOBIN 3018387401_1 CDM 301 RC 83874 HCPCS outpatient 159 119.25 MOLINA MCR ADV MOLINA MCR ADV 141.51 89 999999999 124.02 151.05 percent of total billed charges MYOGLOBIN 3018387401_1 CDM 301 RC 83874 HCPCS outpatient 159 119.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 141.51 89 999999999 124.02 151.05 percent of total billed charges MYOGLOBIN 3018387401_1 CDM 301 RC 83874 HCPCS outpatient 159 119.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 141.51 89 999999999 124.02 151.05 percent of total billed charges MYOGLOBIN 3018387401_1 CDM 301 RC 83874 HCPCS outpatient 159 119.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 143.1 90 999999999 124.02 151.05 percent of total billed charges MYOGLOBIN 3018387401_1 CDM 301 RC 83874 HCPCS outpatient 159 119.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 151.05 95 999999999 124.02 151.05 percent of total billed charges MYOGLOBIN 3018387401_1 CDM 301 RC 83874 HCPCS outpatient 159 119.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 151.05 95 999999999 124.02 151.05 percent of total billed charges MYOGLOBIN 3018387401_1 CDM 301 RC 83874 HCPCS outpatient 159 119.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 141.51 89 999999999 124.02 151.05 percent of total billed charges MYOGLOBIN 3018387401_1 CDM 301 RC 83874 HCPCS outpatient 159 119.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 139.92 88 999999999 124.02 151.05 percent of total billed charges MYOGLOBIN 3018387401_1 CDM 301 RC 83874 HCPCS outpatient 159 119.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 141.51 89 999999999 124.02 151.05 percent of total billed charges NATRIURETIC PEPTIDE 3018388001_1 CDM 301 RC 83880 HCPCS outpatient 340 255 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 306 90 999999999 265.2 323 percent of total billed charges NATRIURETIC PEPTIDE 3018388001_1 CDM 301 RC 83880 HCPCS outpatient 340 255 AETNA MCR ADV AETNA MCR ADV 265.2 78 999999999 265.2 323 percent of total billed charges NATRIURETIC PEPTIDE 3018388001_1 CDM 301 RC 83880 HCPCS outpatient 340 255 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 297.74 87.57 999999999 265.2 323 percent of total billed charges NATRIURETIC PEPTIDE 3018388001_1 CDM 301 RC 83880 HCPCS outpatient 340 255 COORDINATED CARE MCAID COORDINATED CARE MCAID 289.24 85.07 999999999 265.2 323 percent of total billed charges NATRIURETIC PEPTIDE 3018388001_1 CDM 301 RC 83880 HCPCS outpatient 340 255 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 289.24 85.07 999999999 265.2 323 percent of total billed charges NATRIURETIC PEPTIDE 3018388001_1 CDM 301 RC 83880 HCPCS outpatient 340 255 MOLINA MCAID MOLINA MCAID 283.56 83.4 999999999 265.2 323 percent of total billed charges NATRIURETIC PEPTIDE 3018388001_1 CDM 301 RC 83880 HCPCS outpatient 340 255 MOLINA MCR ADV MOLINA MCR ADV 302.6 89 999999999 265.2 323 percent of total billed charges NATRIURETIC PEPTIDE 3018388001_1 CDM 301 RC 83880 HCPCS outpatient 340 255 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 302.6 89 999999999 265.2 323 percent of total billed charges NATRIURETIC PEPTIDE 3018388001_1 CDM 301 RC 83880 HCPCS outpatient 340 255 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 302.6 89 999999999 265.2 323 percent of total billed charges NATRIURETIC PEPTIDE 3018388001_1 CDM 301 RC 83880 HCPCS outpatient 340 255 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 306 90 999999999 265.2 323 percent of total billed charges NATRIURETIC PEPTIDE 3018388001_1 CDM 301 RC 83880 HCPCS outpatient 340 255 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 323 95 999999999 265.2 323 percent of total billed charges NATRIURETIC PEPTIDE 3018388001_1 CDM 301 RC 83880 HCPCS outpatient 340 255 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 323 95 999999999 265.2 323 percent of total billed charges NATRIURETIC PEPTIDE 3018388001_1 CDM 301 RC 83880 HCPCS outpatient 340 255 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 302.6 89 999999999 265.2 323 percent of total billed charges NATRIURETIC PEPTIDE 3018388001_1 CDM 301 RC 83880 HCPCS outpatient 340 255 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 299.2 88 999999999 265.2 323 percent of total billed charges NATRIURETIC PEPTIDE 3018388001_1 CDM 301 RC 83880 HCPCS outpatient 340 255 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 302.6 89 999999999 265.2 323 percent of total billed charges OSMOLALITY; BLOOD 3018393001_1 CDM 301 RC 83930 HCPCS outpatient 65 48.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 58.5 90 999999999 50.7 61.75 percent of total billed charges OSMOLALITY; BLOOD 3018393001_1 CDM 301 RC 83930 HCPCS outpatient 65 48.75 AETNA MCR ADV AETNA MCR ADV 50.7 78 999999999 50.7 61.75 percent of total billed charges OSMOLALITY; BLOOD 3018393001_1 CDM 301 RC 83930 HCPCS outpatient 65 48.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 56.92 87.57 999999999 50.7 61.75 percent of total billed charges OSMOLALITY; BLOOD 3018393001_1 CDM 301 RC 83930 HCPCS outpatient 65 48.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 55.3 85.07 999999999 50.7 61.75 percent of total billed charges OSMOLALITY; BLOOD 3018393001_1 CDM 301 RC 83930 HCPCS outpatient 65 48.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 55.3 85.07 999999999 50.7 61.75 percent of total billed charges OSMOLALITY; BLOOD 3018393001_1 CDM 301 RC 83930 HCPCS outpatient 65 48.75 MOLINA MCAID MOLINA MCAID 54.21 83.4 999999999 50.7 61.75 percent of total billed charges OSMOLALITY; BLOOD 3018393001_1 CDM 301 RC 83930 HCPCS outpatient 65 48.75 MOLINA MCR ADV MOLINA MCR ADV 57.85 89 999999999 50.7 61.75 percent of total billed charges OSMOLALITY; BLOOD 3018393001_1 CDM 301 RC 83930 HCPCS outpatient 65 48.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 57.85 89 999999999 50.7 61.75 percent of total billed charges OSMOLALITY; BLOOD 3018393001_1 CDM 301 RC 83930 HCPCS outpatient 65 48.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 57.85 89 999999999 50.7 61.75 percent of total billed charges OSMOLALITY; BLOOD 3018393001_1 CDM 301 RC 83930 HCPCS outpatient 65 48.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 58.5 90 999999999 50.7 61.75 percent of total billed charges OSMOLALITY; BLOOD 3018393001_1 CDM 301 RC 83930 HCPCS outpatient 65 48.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 61.75 95 999999999 50.7 61.75 percent of total billed charges OSMOLALITY; BLOOD 3018393001_1 CDM 301 RC 83930 HCPCS outpatient 65 48.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 61.75 95 999999999 50.7 61.75 percent of total billed charges OSMOLALITY; BLOOD 3018393001_1 CDM 301 RC 83930 HCPCS outpatient 65 48.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 57.85 89 999999999 50.7 61.75 percent of total billed charges OSMOLALITY; BLOOD 3018393001_1 CDM 301 RC 83930 HCPCS outpatient 65 48.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 57.2 88 999999999 50.7 61.75 percent of total billed charges OSMOLALITY; BLOOD 3018393001_1 CDM 301 RC 83930 HCPCS outpatient 65 48.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 57.85 89 999999999 50.7 61.75 percent of total billed charges OSMOLALITY; URINE 3018393501_1 CDM 301 RC 83935 HCPCS outpatient 86 64.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 77.4 90 999999999 67.08 81.7 percent of total billed charges OSMOLALITY; URINE 3018393501_1 CDM 301 RC 83935 HCPCS outpatient 86 64.5 AETNA MCR ADV AETNA MCR ADV 67.08 78 999999999 67.08 81.7 percent of total billed charges OSMOLALITY; URINE 3018393501_1 CDM 301 RC 83935 HCPCS outpatient 86 64.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 75.31 87.57 999999999 67.08 81.7 percent of total billed charges OSMOLALITY; URINE 3018393501_1 CDM 301 RC 83935 HCPCS outpatient 86 64.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 73.16 85.07 999999999 67.08 81.7 percent of total billed charges OSMOLALITY; URINE 3018393501_1 CDM 301 RC 83935 HCPCS outpatient 86 64.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 73.16 85.07 999999999 67.08 81.7 percent of total billed charges OSMOLALITY; URINE 3018393501_1 CDM 301 RC 83935 HCPCS outpatient 86 64.5 MOLINA MCAID MOLINA MCAID 71.72 83.4 999999999 67.08 81.7 percent of total billed charges OSMOLALITY; URINE 3018393501_1 CDM 301 RC 83935 HCPCS outpatient 86 64.5 MOLINA MCR ADV MOLINA MCR ADV 76.54 89 999999999 67.08 81.7 percent of total billed charges OSMOLALITY; URINE 3018393501_1 CDM 301 RC 83935 HCPCS outpatient 86 64.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 76.54 89 999999999 67.08 81.7 percent of total billed charges OSMOLALITY; URINE 3018393501_1 CDM 301 RC 83935 HCPCS outpatient 86 64.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 76.54 89 999999999 67.08 81.7 percent of total billed charges OSMOLALITY; URINE 3018393501_1 CDM 301 RC 83935 HCPCS outpatient 86 64.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 77.4 90 999999999 67.08 81.7 percent of total billed charges OSMOLALITY; URINE 3018393501_1 CDM 301 RC 83935 HCPCS outpatient 86 64.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 81.7 95 999999999 67.08 81.7 percent of total billed charges OSMOLALITY; URINE 3018393501_1 CDM 301 RC 83935 HCPCS outpatient 86 64.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 81.7 95 999999999 67.08 81.7 percent of total billed charges OSMOLALITY; URINE 3018393501_1 CDM 301 RC 83935 HCPCS outpatient 86 64.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 76.54 89 999999999 67.08 81.7 percent of total billed charges OSMOLALITY; URINE 3018393501_1 CDM 301 RC 83935 HCPCS outpatient 86 64.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 75.68 88 999999999 67.08 81.7 percent of total billed charges OSMOLALITY; URINE 3018393501_1 CDM 301 RC 83935 HCPCS outpatient 86 64.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 76.54 89 999999999 67.08 81.7 percent of total billed charges PARATHORMONE (PARATHYROID HORMONE) 3018397001_1 CDM 301 RC 83970 HCPCS outpatient 243 182.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 218.7 90 999999999 189.54 230.85 percent of total billed charges PARATHORMONE (PARATHYROID HORMONE) 3018397001_1 CDM 301 RC 83970 HCPCS outpatient 243 182.25 AETNA MCR ADV AETNA MCR ADV 189.54 78 999999999 189.54 230.85 percent of total billed charges PARATHORMONE (PARATHYROID HORMONE) 3018397001_1 CDM 301 RC 83970 HCPCS outpatient 243 182.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 212.8 87.57 999999999 189.54 230.85 percent of total billed charges PARATHORMONE (PARATHYROID HORMONE) 3018397001_1 CDM 301 RC 83970 HCPCS outpatient 243 182.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 206.72 85.07 999999999 189.54 230.85 percent of total billed charges PARATHORMONE (PARATHYROID HORMONE) 3018397001_1 CDM 301 RC 83970 HCPCS outpatient 243 182.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 206.72 85.07 999999999 189.54 230.85 percent of total billed charges PARATHORMONE (PARATHYROID HORMONE) 3018397001_1 CDM 301 RC 83970 HCPCS outpatient 243 182.25 MOLINA MCAID MOLINA MCAID 202.66 83.4 999999999 189.54 230.85 percent of total billed charges PARATHORMONE (PARATHYROID HORMONE) 3018397001_1 CDM 301 RC 83970 HCPCS outpatient 243 182.25 MOLINA MCR ADV MOLINA MCR ADV 216.27 89 999999999 189.54 230.85 percent of total billed charges PARATHORMONE (PARATHYROID HORMONE) 3018397001_1 CDM 301 RC 83970 HCPCS outpatient 243 182.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 216.27 89 999999999 189.54 230.85 percent of total billed charges PARATHORMONE (PARATHYROID HORMONE) 3018397001_1 CDM 301 RC 83970 HCPCS outpatient 243 182.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 216.27 89 999999999 189.54 230.85 percent of total billed charges PARATHORMONE (PARATHYROID HORMONE) 3018397001_1 CDM 301 RC 83970 HCPCS outpatient 243 182.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 218.7 90 999999999 189.54 230.85 percent of total billed charges PARATHORMONE (PARATHYROID HORMONE) 3018397001_1 CDM 301 RC 83970 HCPCS outpatient 243 182.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 230.85 95 999999999 189.54 230.85 percent of total billed charges PARATHORMONE (PARATHYROID HORMONE) 3018397001_1 CDM 301 RC 83970 HCPCS outpatient 243 182.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 230.85 95 999999999 189.54 230.85 percent of total billed charges PARATHORMONE (PARATHYROID HORMONE) 3018397001_1 CDM 301 RC 83970 HCPCS outpatient 243 182.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 216.27 89 999999999 189.54 230.85 percent of total billed charges PARATHORMONE (PARATHYROID HORMONE) 3018397001_1 CDM 301 RC 83970 HCPCS outpatient 243 182.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 213.84 88 999999999 189.54 230.85 percent of total billed charges PARATHORMONE (PARATHYROID HORMONE) 3018397001_1 CDM 301 RC 83970 HCPCS outpatient 243 182.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 216.27 89 999999999 189.54 230.85 percent of total billed charges "CALPROTECTIN, FECAL" 3018399301_1 CDM 301 RC 83993 HCPCS outpatient 304 228 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 273.6 90 999999999 237.12 288.8 percent of total billed charges "CALPROTECTIN, FECAL" 3018399301_1 CDM 301 RC 83993 HCPCS outpatient 304 228 AETNA MCR ADV AETNA MCR ADV 237.12 78 999999999 237.12 288.8 percent of total billed charges "CALPROTECTIN, FECAL" 3018399301_1 CDM 301 RC 83993 HCPCS outpatient 304 228 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 266.21 87.57 999999999 237.12 288.8 percent of total billed charges "CALPROTECTIN, FECAL" 3018399301_1 CDM 301 RC 83993 HCPCS outpatient 304 228 COORDINATED CARE MCAID COORDINATED CARE MCAID 258.61 85.07 999999999 237.12 288.8 percent of total billed charges "CALPROTECTIN, FECAL" 3018399301_1 CDM 301 RC 83993 HCPCS outpatient 304 228 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 258.61 85.07 999999999 237.12 288.8 percent of total billed charges "CALPROTECTIN, FECAL" 3018399301_1 CDM 301 RC 83993 HCPCS outpatient 304 228 MOLINA MCAID MOLINA MCAID 253.54 83.4 999999999 237.12 288.8 percent of total billed charges "CALPROTECTIN, FECAL" 3018399301_1 CDM 301 RC 83993 HCPCS outpatient 304 228 MOLINA MCR ADV MOLINA MCR ADV 270.56 89 999999999 237.12 288.8 percent of total billed charges "CALPROTECTIN, FECAL" 3018399301_1 CDM 301 RC 83993 HCPCS outpatient 304 228 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 270.56 89 999999999 237.12 288.8 percent of total billed charges "CALPROTECTIN, FECAL" 3018399301_1 CDM 301 RC 83993 HCPCS outpatient 304 228 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 270.56 89 999999999 237.12 288.8 percent of total billed charges "CALPROTECTIN, FECAL" 3018399301_1 CDM 301 RC 83993 HCPCS outpatient 304 228 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 273.6 90 999999999 237.12 288.8 percent of total billed charges "CALPROTECTIN, FECAL" 3018399301_1 CDM 301 RC 83993 HCPCS outpatient 304 228 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 288.8 95 999999999 237.12 288.8 percent of total billed charges "CALPROTECTIN, FECAL" 3018399301_1 CDM 301 RC 83993 HCPCS outpatient 304 228 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 288.8 95 999999999 237.12 288.8 percent of total billed charges "CALPROTECTIN, FECAL" 3018399301_1 CDM 301 RC 83993 HCPCS outpatient 304 228 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 270.56 89 999999999 237.12 288.8 percent of total billed charges "CALPROTECTIN, FECAL" 3018399301_1 CDM 301 RC 83993 HCPCS outpatient 304 228 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 267.52 88 999999999 237.12 288.8 percent of total billed charges "CALPROTECTIN, FECAL" 3018399301_1 CDM 301 RC 83993 HCPCS outpatient 304 228 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 270.56 89 999999999 237.12 288.8 percent of total billed charges "PHENYLALANINE (PKU), BLOOD" 3018403001_1 CDM 301 RC 84030 HCPCS outpatient 150 112.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 135 90 999999999 117 142.5 percent of total billed charges "PHENYLALANINE (PKU), BLOOD" 3018403001_1 CDM 301 RC 84030 HCPCS outpatient 150 112.5 AETNA MCR ADV AETNA MCR ADV 117 78 999999999 117 142.5 percent of total billed charges "PHENYLALANINE (PKU), BLOOD" 3018403001_1 CDM 301 RC 84030 HCPCS outpatient 150 112.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 131.36 87.57 999999999 117 142.5 percent of total billed charges "PHENYLALANINE (PKU), BLOOD" 3018403001_1 CDM 301 RC 84030 HCPCS outpatient 150 112.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 127.61 85.07 999999999 117 142.5 percent of total billed charges "PHENYLALANINE (PKU), BLOOD" 3018403001_1 CDM 301 RC 84030 HCPCS outpatient 150 112.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 127.61 85.07 999999999 117 142.5 percent of total billed charges "PHENYLALANINE (PKU), BLOOD" 3018403001_1 CDM 301 RC 84030 HCPCS outpatient 150 112.5 MOLINA MCAID MOLINA MCAID 125.1 83.4 999999999 117 142.5 percent of total billed charges "PHENYLALANINE (PKU), BLOOD" 3018403001_1 CDM 301 RC 84030 HCPCS outpatient 150 112.5 MOLINA MCR ADV MOLINA MCR ADV 133.5 89 999999999 117 142.5 percent of total billed charges "PHENYLALANINE (PKU), BLOOD" 3018403001_1 CDM 301 RC 84030 HCPCS outpatient 150 112.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 133.5 89 999999999 117 142.5 percent of total billed charges "PHENYLALANINE (PKU), BLOOD" 3018403001_1 CDM 301 RC 84030 HCPCS outpatient 150 112.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 133.5 89 999999999 117 142.5 percent of total billed charges "PHENYLALANINE (PKU), BLOOD" 3018403001_1 CDM 301 RC 84030 HCPCS outpatient 150 112.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 135 90 999999999 117 142.5 percent of total billed charges "PHENYLALANINE (PKU), BLOOD" 3018403001_1 CDM 301 RC 84030 HCPCS outpatient 150 112.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 142.5 95 999999999 117 142.5 percent of total billed charges "PHENYLALANINE (PKU), BLOOD" 3018403001_1 CDM 301 RC 84030 HCPCS outpatient 150 112.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 142.5 95 999999999 117 142.5 percent of total billed charges "PHENYLALANINE (PKU), BLOOD" 3018403001_1 CDM 301 RC 84030 HCPCS outpatient 150 112.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 133.5 89 999999999 117 142.5 percent of total billed charges "PHENYLALANINE (PKU), BLOOD" 3018403001_1 CDM 301 RC 84030 HCPCS outpatient 150 112.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 132 88 999999999 117 142.5 percent of total billed charges "PHENYLALANINE (PKU), BLOOD" 3018403001_1 CDM 301 RC 84030 HCPCS outpatient 150 112.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 133.5 89 999999999 117 142.5 percent of total billed charges "PHOSPHATASE, ALKALINE" 3018407501_1 CDM 301 RC 84075 HCPCS outpatient 52 39 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 46.8 90 999999999 40.56 49.4 percent of total billed charges "PHOSPHATASE, ALKALINE" 3018407501_1 CDM 301 RC 84075 HCPCS outpatient 52 39 AETNA MCR ADV AETNA MCR ADV 40.56 78 999999999 40.56 49.4 percent of total billed charges "PHOSPHATASE, ALKALINE" 3018407501_1 CDM 301 RC 84075 HCPCS outpatient 52 39 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 45.54 87.57 999999999 40.56 49.4 percent of total billed charges "PHOSPHATASE, ALKALINE" 3018407501_1 CDM 301 RC 84075 HCPCS outpatient 52 39 COORDINATED CARE MCAID COORDINATED CARE MCAID 44.24 85.07 999999999 40.56 49.4 percent of total billed charges "PHOSPHATASE, ALKALINE" 3018407501_1 CDM 301 RC 84075 HCPCS outpatient 52 39 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 44.24 85.07 999999999 40.56 49.4 percent of total billed charges "PHOSPHATASE, ALKALINE" 3018407501_1 CDM 301 RC 84075 HCPCS outpatient 52 39 MOLINA MCAID MOLINA MCAID 43.37 83.4 999999999 40.56 49.4 percent of total billed charges "PHOSPHATASE, ALKALINE" 3018407501_1 CDM 301 RC 84075 HCPCS outpatient 52 39 MOLINA MCR ADV MOLINA MCR ADV 46.28 89 999999999 40.56 49.4 percent of total billed charges "PHOSPHATASE, ALKALINE" 3018407501_1 CDM 301 RC 84075 HCPCS outpatient 52 39 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 46.28 89 999999999 40.56 49.4 percent of total billed charges "PHOSPHATASE, ALKALINE" 3018407501_1 CDM 301 RC 84075 HCPCS outpatient 52 39 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 46.28 89 999999999 40.56 49.4 percent of total billed charges "PHOSPHATASE, ALKALINE" 3018407501_1 CDM 301 RC 84075 HCPCS outpatient 52 39 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 46.8 90 999999999 40.56 49.4 percent of total billed charges "PHOSPHATASE, ALKALINE" 3018407501_1 CDM 301 RC 84075 HCPCS outpatient 52 39 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 49.4 95 999999999 40.56 49.4 percent of total billed charges "PHOSPHATASE, ALKALINE" 3018407501_1 CDM 301 RC 84075 HCPCS outpatient 52 39 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 49.4 95 999999999 40.56 49.4 percent of total billed charges "PHOSPHATASE, ALKALINE" 3018407501_1 CDM 301 RC 84075 HCPCS outpatient 52 39 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 46.28 89 999999999 40.56 49.4 percent of total billed charges "PHOSPHATASE, ALKALINE" 3018407501_1 CDM 301 RC 84075 HCPCS outpatient 52 39 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 45.76 88 999999999 40.56 49.4 percent of total billed charges "PHOSPHATASE, ALKALINE" 3018407501_1 CDM 301 RC 84075 HCPCS outpatient 52 39 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 46.28 89 999999999 40.56 49.4 percent of total billed charges PHOSPHORUS INORGANIC (PHOSPHATE) 3018410001_1 CDM 301 RC 84100 HCPCS outpatient 64 48 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 57.6 90 999999999 49.92 60.8 percent of total billed charges PHOSPHORUS INORGANIC (PHOSPHATE) 3018410001_1 CDM 301 RC 84100 HCPCS outpatient 64 48 AETNA MCR ADV AETNA MCR ADV 49.92 78 999999999 49.92 60.8 percent of total billed charges PHOSPHORUS INORGANIC (PHOSPHATE) 3018410001_1 CDM 301 RC 84100 HCPCS outpatient 64 48 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 56.04 87.57 999999999 49.92 60.8 percent of total billed charges PHOSPHORUS INORGANIC (PHOSPHATE) 3018410001_1 CDM 301 RC 84100 HCPCS outpatient 64 48 COORDINATED CARE MCAID COORDINATED CARE MCAID 54.44 85.07 999999999 49.92 60.8 percent of total billed charges PHOSPHORUS INORGANIC (PHOSPHATE) 3018410001_1 CDM 301 RC 84100 HCPCS outpatient 64 48 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 54.44 85.07 999999999 49.92 60.8 percent of total billed charges PHOSPHORUS INORGANIC (PHOSPHATE) 3018410001_1 CDM 301 RC 84100 HCPCS outpatient 64 48 MOLINA MCAID MOLINA MCAID 53.38 83.4 999999999 49.92 60.8 percent of total billed charges PHOSPHORUS INORGANIC (PHOSPHATE) 3018410001_1 CDM 301 RC 84100 HCPCS outpatient 64 48 MOLINA MCR ADV MOLINA MCR ADV 56.96 89 999999999 49.92 60.8 percent of total billed charges PHOSPHORUS INORGANIC (PHOSPHATE) 3018410001_1 CDM 301 RC 84100 HCPCS outpatient 64 48 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 56.96 89 999999999 49.92 60.8 percent of total billed charges PHOSPHORUS INORGANIC (PHOSPHATE) 3018410001_1 CDM 301 RC 84100 HCPCS outpatient 64 48 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 56.96 89 999999999 49.92 60.8 percent of total billed charges PHOSPHORUS INORGANIC (PHOSPHATE) 3018410001_1 CDM 301 RC 84100 HCPCS outpatient 64 48 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 57.6 90 999999999 49.92 60.8 percent of total billed charges PHOSPHORUS INORGANIC (PHOSPHATE) 3018410001_1 CDM 301 RC 84100 HCPCS outpatient 64 48 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 60.8 95 999999999 49.92 60.8 percent of total billed charges PHOSPHORUS INORGANIC (PHOSPHATE) 3018410001_1 CDM 301 RC 84100 HCPCS outpatient 64 48 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 60.8 95 999999999 49.92 60.8 percent of total billed charges PHOSPHORUS INORGANIC (PHOSPHATE) 3018410001_1 CDM 301 RC 84100 HCPCS outpatient 64 48 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 56.96 89 999999999 49.92 60.8 percent of total billed charges PHOSPHORUS INORGANIC (PHOSPHATE) 3018410001_1 CDM 301 RC 84100 HCPCS outpatient 64 48 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 56.32 88 999999999 49.92 60.8 percent of total billed charges PHOSPHORUS INORGANIC (PHOSPHATE) 3018410001_1 CDM 301 RC 84100 HCPCS outpatient 64 48 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 56.96 89 999999999 49.92 60.8 percent of total billed charges "POTASSIUM; SERUM, PLASMA OR WHOLE BLOOD" 3018413201_1 CDM 301 RC 84132 HCPCS outpatient 57 42.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 51.3 90 999999999 44.46 54.15 percent of total billed charges "POTASSIUM; SERUM, PLASMA OR WHOLE BLOOD" 3018413201_1 CDM 301 RC 84132 HCPCS outpatient 57 42.75 AETNA MCR ADV AETNA MCR ADV 44.46 78 999999999 44.46 54.15 percent of total billed charges "POTASSIUM; SERUM, PLASMA OR WHOLE BLOOD" 3018413201_1 CDM 301 RC 84132 HCPCS outpatient 57 42.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 49.91 87.57 999999999 44.46 54.15 percent of total billed charges "POTASSIUM; SERUM, PLASMA OR WHOLE BLOOD" 3018413201_1 CDM 301 RC 84132 HCPCS outpatient 57 42.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 48.49 85.07 999999999 44.46 54.15 percent of total billed charges "POTASSIUM; SERUM, PLASMA OR WHOLE BLOOD" 3018413201_1 CDM 301 RC 84132 HCPCS outpatient 57 42.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 48.49 85.07 999999999 44.46 54.15 percent of total billed charges "POTASSIUM; SERUM, PLASMA OR WHOLE BLOOD" 3018413201_1 CDM 301 RC 84132 HCPCS outpatient 57 42.75 MOLINA MCAID MOLINA MCAID 47.54 83.4 999999999 44.46 54.15 percent of total billed charges "POTASSIUM; SERUM, PLASMA OR WHOLE BLOOD" 3018413201_1 CDM 301 RC 84132 HCPCS outpatient 57 42.75 MOLINA MCR ADV MOLINA MCR ADV 50.73 89 999999999 44.46 54.15 percent of total billed charges "POTASSIUM; SERUM, PLASMA OR WHOLE BLOOD" 3018413201_1 CDM 301 RC 84132 HCPCS outpatient 57 42.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50.73 89 999999999 44.46 54.15 percent of total billed charges "POTASSIUM; SERUM, PLASMA OR WHOLE BLOOD" 3018413201_1 CDM 301 RC 84132 HCPCS outpatient 57 42.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50.73 89 999999999 44.46 54.15 percent of total billed charges "POTASSIUM; SERUM, PLASMA OR WHOLE BLOOD" 3018413201_1 CDM 301 RC 84132 HCPCS outpatient 57 42.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 51.3 90 999999999 44.46 54.15 percent of total billed charges "POTASSIUM; SERUM, PLASMA OR WHOLE BLOOD" 3018413201_1 CDM 301 RC 84132 HCPCS outpatient 57 42.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 54.15 95 999999999 44.46 54.15 percent of total billed charges "POTASSIUM; SERUM, PLASMA OR WHOLE BLOOD" 3018413201_1 CDM 301 RC 84132 HCPCS outpatient 57 42.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 54.15 95 999999999 44.46 54.15 percent of total billed charges "POTASSIUM; SERUM, PLASMA OR WHOLE BLOOD" 3018413201_1 CDM 301 RC 84132 HCPCS outpatient 57 42.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50.73 89 999999999 44.46 54.15 percent of total billed charges "POTASSIUM; SERUM, PLASMA OR WHOLE BLOOD" 3018413201_1 CDM 301 RC 84132 HCPCS outpatient 57 42.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50.16 88 999999999 44.46 54.15 percent of total billed charges "POTASSIUM; SERUM, PLASMA OR WHOLE BLOOD" 3018413201_1 CDM 301 RC 84132 HCPCS outpatient 57 42.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50.73 89 999999999 44.46 54.15 percent of total billed charges POTASSIUM; URINE 3018413301_1 CDM 301 RC 84133 HCPCS outpatient 55 41.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 49.5 90 999999999 42.9 52.25 percent of total billed charges POTASSIUM; URINE 3018413301_1 CDM 301 RC 84133 HCPCS outpatient 55 41.25 AETNA MCR ADV AETNA MCR ADV 42.9 78 999999999 42.9 52.25 percent of total billed charges POTASSIUM; URINE 3018413301_1 CDM 301 RC 84133 HCPCS outpatient 55 41.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 48.16 87.57 999999999 42.9 52.25 percent of total billed charges POTASSIUM; URINE 3018413301_1 CDM 301 RC 84133 HCPCS outpatient 55 41.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 46.79 85.07 999999999 42.9 52.25 percent of total billed charges POTASSIUM; URINE 3018413301_1 CDM 301 RC 84133 HCPCS outpatient 55 41.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 46.79 85.07 999999999 42.9 52.25 percent of total billed charges POTASSIUM; URINE 3018413301_1 CDM 301 RC 84133 HCPCS outpatient 55 41.25 MOLINA MCAID MOLINA MCAID 45.87 83.4 999999999 42.9 52.25 percent of total billed charges POTASSIUM; URINE 3018413301_1 CDM 301 RC 84133 HCPCS outpatient 55 41.25 MOLINA MCR ADV MOLINA MCR ADV 48.95 89 999999999 42.9 52.25 percent of total billed charges POTASSIUM; URINE 3018413301_1 CDM 301 RC 84133 HCPCS outpatient 55 41.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 48.95 89 999999999 42.9 52.25 percent of total billed charges POTASSIUM; URINE 3018413301_1 CDM 301 RC 84133 HCPCS outpatient 55 41.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 48.95 89 999999999 42.9 52.25 percent of total billed charges POTASSIUM; URINE 3018413301_1 CDM 301 RC 84133 HCPCS outpatient 55 41.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 49.5 90 999999999 42.9 52.25 percent of total billed charges POTASSIUM; URINE 3018413301_1 CDM 301 RC 84133 HCPCS outpatient 55 41.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 52.25 95 999999999 42.9 52.25 percent of total billed charges POTASSIUM; URINE 3018413301_1 CDM 301 RC 84133 HCPCS outpatient 55 41.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 52.25 95 999999999 42.9 52.25 percent of total billed charges POTASSIUM; URINE 3018413301_1 CDM 301 RC 84133 HCPCS outpatient 55 41.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 48.95 89 999999999 42.9 52.25 percent of total billed charges POTASSIUM; URINE 3018413301_1 CDM 301 RC 84133 HCPCS outpatient 55 41.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 48.4 88 999999999 42.9 52.25 percent of total billed charges POTASSIUM; URINE 3018413301_1 CDM 301 RC 84133 HCPCS outpatient 55 41.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 48.95 89 999999999 42.9 52.25 percent of total billed charges PREALBUMIN 3018413402_1 CDM 301 RC 84134 HCPCS outpatient 139 104.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 125.1 90 999999999 108.42 132.05 percent of total billed charges PREALBUMIN 3018413402_1 CDM 301 RC 84134 HCPCS outpatient 139 104.25 AETNA MCR ADV AETNA MCR ADV 108.42 78 999999999 108.42 132.05 percent of total billed charges PREALBUMIN 3018413402_1 CDM 301 RC 84134 HCPCS outpatient 139 104.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 121.72 87.57 999999999 108.42 132.05 percent of total billed charges PREALBUMIN 3018413402_1 CDM 301 RC 84134 HCPCS outpatient 139 104.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 118.25 85.07 999999999 108.42 132.05 percent of total billed charges PREALBUMIN 3018413402_1 CDM 301 RC 84134 HCPCS outpatient 139 104.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 118.25 85.07 999999999 108.42 132.05 percent of total billed charges PREALBUMIN 3018413402_1 CDM 301 RC 84134 HCPCS outpatient 139 104.25 MOLINA MCAID MOLINA MCAID 115.93 83.4 999999999 108.42 132.05 percent of total billed charges PREALBUMIN 3018413402_1 CDM 301 RC 84134 HCPCS outpatient 139 104.25 MOLINA MCR ADV MOLINA MCR ADV 123.71 89 999999999 108.42 132.05 percent of total billed charges PREALBUMIN 3018413402_1 CDM 301 RC 84134 HCPCS outpatient 139 104.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 123.71 89 999999999 108.42 132.05 percent of total billed charges PREALBUMIN 3018413402_1 CDM 301 RC 84134 HCPCS outpatient 139 104.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 123.71 89 999999999 108.42 132.05 percent of total billed charges PREALBUMIN 3018413402_1 CDM 301 RC 84134 HCPCS outpatient 139 104.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 125.1 90 999999999 108.42 132.05 percent of total billed charges PREALBUMIN 3018413402_1 CDM 301 RC 84134 HCPCS outpatient 139 104.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 132.05 95 999999999 108.42 132.05 percent of total billed charges PREALBUMIN 3018413402_1 CDM 301 RC 84134 HCPCS outpatient 139 104.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 132.05 95 999999999 108.42 132.05 percent of total billed charges PREALBUMIN 3018413402_1 CDM 301 RC 84134 HCPCS outpatient 139 104.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 123.71 89 999999999 108.42 132.05 percent of total billed charges PREALBUMIN 3018413402_1 CDM 301 RC 84134 HCPCS outpatient 139 104.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 122.32 88 999999999 108.42 132.05 percent of total billed charges PREALBUMIN 3018413402_1 CDM 301 RC 84134 HCPCS outpatient 139 104.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 123.71 89 999999999 108.42 132.05 percent of total billed charges PROGESTERONE 3018414401_1 CDM 301 RC 84144 HCPCS outpatient 100 75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 90 90 999999999 78 95 percent of total billed charges PROGESTERONE 3018414401_1 CDM 301 RC 84144 HCPCS outpatient 100 75 AETNA MCR ADV AETNA MCR ADV 78 78 999999999 78 95 percent of total billed charges PROGESTERONE 3018414401_1 CDM 301 RC 84144 HCPCS outpatient 100 75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 87.57 87.57 999999999 78 95 percent of total billed charges PROGESTERONE 3018414401_1 CDM 301 RC 84144 HCPCS outpatient 100 75 COORDINATED CARE MCAID COORDINATED CARE MCAID 85.07 85.07 999999999 78 95 percent of total billed charges PROGESTERONE 3018414401_1 CDM 301 RC 84144 HCPCS outpatient 100 75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 85.07 85.07 999999999 78 95 percent of total billed charges PROGESTERONE 3018414401_1 CDM 301 RC 84144 HCPCS outpatient 100 75 MOLINA MCAID MOLINA MCAID 83.4 83.4 999999999 78 95 percent of total billed charges PROGESTERONE 3018414401_1 CDM 301 RC 84144 HCPCS outpatient 100 75 MOLINA MCR ADV MOLINA MCR ADV 89 89 999999999 78 95 percent of total billed charges PROGESTERONE 3018414401_1 CDM 301 RC 84144 HCPCS outpatient 100 75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 89 89 999999999 78 95 percent of total billed charges PROGESTERONE 3018414401_1 CDM 301 RC 84144 HCPCS outpatient 100 75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 89 89 999999999 78 95 percent of total billed charges PROGESTERONE 3018414401_1 CDM 301 RC 84144 HCPCS outpatient 100 75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 90 90 999999999 78 95 percent of total billed charges PROGESTERONE 3018414401_1 CDM 301 RC 84144 HCPCS outpatient 100 75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 95 95 999999999 78 95 percent of total billed charges PROGESTERONE 3018414401_1 CDM 301 RC 84144 HCPCS outpatient 100 75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 95 95 999999999 78 95 percent of total billed charges PROGESTERONE 3018414401_1 CDM 301 RC 84144 HCPCS outpatient 100 75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 89 89 999999999 78 95 percent of total billed charges PROGESTERONE 3018414401_1 CDM 301 RC 84144 HCPCS outpatient 100 75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 88 88 999999999 78 95 percent of total billed charges PROGESTERONE 3018414401_1 CDM 301 RC 84144 HCPCS outpatient 100 75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 89 89 999999999 78 95 percent of total billed charges PROLACTIN 3018414601_1 CDM 301 RC 84146 HCPCS outpatient 133 99.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 119.7 90 999999999 103.74 126.35 percent of total billed charges PROLACTIN 3018414601_1 CDM 301 RC 84146 HCPCS outpatient 133 99.75 AETNA MCR ADV AETNA MCR ADV 103.74 78 999999999 103.74 126.35 percent of total billed charges PROLACTIN 3018414601_1 CDM 301 RC 84146 HCPCS outpatient 133 99.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 116.47 87.57 999999999 103.74 126.35 percent of total billed charges PROLACTIN 3018414601_1 CDM 301 RC 84146 HCPCS outpatient 133 99.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 113.14 85.07 999999999 103.74 126.35 percent of total billed charges PROLACTIN 3018414601_1 CDM 301 RC 84146 HCPCS outpatient 133 99.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 113.14 85.07 999999999 103.74 126.35 percent of total billed charges PROLACTIN 3018414601_1 CDM 301 RC 84146 HCPCS outpatient 133 99.75 MOLINA MCAID MOLINA MCAID 110.92 83.4 999999999 103.74 126.35 percent of total billed charges PROLACTIN 3018414601_1 CDM 301 RC 84146 HCPCS outpatient 133 99.75 MOLINA MCR ADV MOLINA MCR ADV 118.37 89 999999999 103.74 126.35 percent of total billed charges PROLACTIN 3018414601_1 CDM 301 RC 84146 HCPCS outpatient 133 99.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 118.37 89 999999999 103.74 126.35 percent of total billed charges PROLACTIN 3018414601_1 CDM 301 RC 84146 HCPCS outpatient 133 99.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 118.37 89 999999999 103.74 126.35 percent of total billed charges PROLACTIN 3018414601_1 CDM 301 RC 84146 HCPCS outpatient 133 99.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 119.7 90 999999999 103.74 126.35 percent of total billed charges PROLACTIN 3018414601_1 CDM 301 RC 84146 HCPCS outpatient 133 99.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 126.35 95 999999999 103.74 126.35 percent of total billed charges PROLACTIN 3018414601_1 CDM 301 RC 84146 HCPCS outpatient 133 99.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 126.35 95 999999999 103.74 126.35 percent of total billed charges PROLACTIN 3018414601_1 CDM 301 RC 84146 HCPCS outpatient 133 99.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 118.37 89 999999999 103.74 126.35 percent of total billed charges PROLACTIN 3018414601_1 CDM 301 RC 84146 HCPCS outpatient 133 99.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 117.04 88 999999999 103.74 126.35 percent of total billed charges PROLACTIN 3018414601_1 CDM 301 RC 84146 HCPCS outpatient 133 99.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 118.37 89 999999999 103.74 126.35 percent of total billed charges PROSTATE SPECIFIC ANTIGEN (PSA); TOTAL 3018415301_1 CDM 301 RC 84153 HCPCS outpatient 118 88.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 106.2 90 999999999 92.04 112.1 percent of total billed charges PROSTATE SPECIFIC ANTIGEN (PSA); TOTAL 3018415301_1 CDM 301 RC 84153 HCPCS outpatient 118 88.5 AETNA MCR ADV AETNA MCR ADV 92.04 78 999999999 92.04 112.1 percent of total billed charges PROSTATE SPECIFIC ANTIGEN (PSA); TOTAL 3018415301_1 CDM 301 RC 84153 HCPCS outpatient 118 88.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 103.33 87.57 999999999 92.04 112.1 percent of total billed charges PROSTATE SPECIFIC ANTIGEN (PSA); TOTAL 3018415301_1 CDM 301 RC 84153 HCPCS outpatient 118 88.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 100.38 85.07 999999999 92.04 112.1 percent of total billed charges PROSTATE SPECIFIC ANTIGEN (PSA); TOTAL 3018415301_1 CDM 301 RC 84153 HCPCS outpatient 118 88.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 100.38 85.07 999999999 92.04 112.1 percent of total billed charges PROSTATE SPECIFIC ANTIGEN (PSA); TOTAL 3018415301_1 CDM 301 RC 84153 HCPCS outpatient 118 88.5 MOLINA MCAID MOLINA MCAID 98.41 83.4 999999999 92.04 112.1 percent of total billed charges PROSTATE SPECIFIC ANTIGEN (PSA); TOTAL 3018415301_1 CDM 301 RC 84153 HCPCS outpatient 118 88.5 MOLINA MCR ADV MOLINA MCR ADV 105.02 89 999999999 92.04 112.1 percent of total billed charges PROSTATE SPECIFIC ANTIGEN (PSA); TOTAL 3018415301_1 CDM 301 RC 84153 HCPCS outpatient 118 88.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 105.02 89 999999999 92.04 112.1 percent of total billed charges PROSTATE SPECIFIC ANTIGEN (PSA); TOTAL 3018415301_1 CDM 301 RC 84153 HCPCS outpatient 118 88.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 105.02 89 999999999 92.04 112.1 percent of total billed charges PROSTATE SPECIFIC ANTIGEN (PSA); TOTAL 3018415301_1 CDM 301 RC 84153 HCPCS outpatient 118 88.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 106.2 90 999999999 92.04 112.1 percent of total billed charges PROSTATE SPECIFIC ANTIGEN (PSA); TOTAL 3018415301_1 CDM 301 RC 84153 HCPCS outpatient 118 88.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 112.1 95 999999999 92.04 112.1 percent of total billed charges PROSTATE SPECIFIC ANTIGEN (PSA); TOTAL 3018415301_1 CDM 301 RC 84153 HCPCS outpatient 118 88.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 112.1 95 999999999 92.04 112.1 percent of total billed charges PROSTATE SPECIFIC ANTIGEN (PSA); TOTAL 3018415301_1 CDM 301 RC 84153 HCPCS outpatient 118 88.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 105.02 89 999999999 92.04 112.1 percent of total billed charges PROSTATE SPECIFIC ANTIGEN (PSA); TOTAL 3018415301_1 CDM 301 RC 84153 HCPCS outpatient 118 88.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 103.84 88 999999999 92.04 112.1 percent of total billed charges PROSTATE SPECIFIC ANTIGEN (PSA); TOTAL 3018415301_1 CDM 301 RC 84153 HCPCS outpatient 118 88.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 105.02 89 999999999 92.04 112.1 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; SERUM, PLASMA OR WHOLE BLOOD" 3018415501_1 CDM 301 RC 84155 HCPCS outpatient 71 53.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 63.9 90 999999999 55.38 67.45 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; SERUM, PLASMA OR WHOLE BLOOD" 3018415501_1 CDM 301 RC 84155 HCPCS outpatient 71 53.25 AETNA MCR ADV AETNA MCR ADV 55.38 78 999999999 55.38 67.45 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; SERUM, PLASMA OR WHOLE BLOOD" 3018415501_1 CDM 301 RC 84155 HCPCS outpatient 71 53.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 62.17 87.57 999999999 55.38 67.45 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; SERUM, PLASMA OR WHOLE BLOOD" 3018415501_1 CDM 301 RC 84155 HCPCS outpatient 71 53.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 60.4 85.07 999999999 55.38 67.45 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; SERUM, PLASMA OR WHOLE BLOOD" 3018415501_1 CDM 301 RC 84155 HCPCS outpatient 71 53.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 60.4 85.07 999999999 55.38 67.45 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; SERUM, PLASMA OR WHOLE BLOOD" 3018415501_1 CDM 301 RC 84155 HCPCS outpatient 71 53.25 MOLINA MCAID MOLINA MCAID 59.21 83.4 999999999 55.38 67.45 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; SERUM, PLASMA OR WHOLE BLOOD" 3018415501_1 CDM 301 RC 84155 HCPCS outpatient 71 53.25 MOLINA MCR ADV MOLINA MCR ADV 63.19 89 999999999 55.38 67.45 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; SERUM, PLASMA OR WHOLE BLOOD" 3018415501_1 CDM 301 RC 84155 HCPCS outpatient 71 53.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 63.19 89 999999999 55.38 67.45 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; SERUM, PLASMA OR WHOLE BLOOD" 3018415501_1 CDM 301 RC 84155 HCPCS outpatient 71 53.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 63.19 89 999999999 55.38 67.45 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; SERUM, PLASMA OR WHOLE BLOOD" 3018415501_1 CDM 301 RC 84155 HCPCS outpatient 71 53.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 63.9 90 999999999 55.38 67.45 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; SERUM, PLASMA OR WHOLE BLOOD" 3018415501_1 CDM 301 RC 84155 HCPCS outpatient 71 53.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 67.45 95 999999999 55.38 67.45 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; SERUM, PLASMA OR WHOLE BLOOD" 3018415501_1 CDM 301 RC 84155 HCPCS outpatient 71 53.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 67.45 95 999999999 55.38 67.45 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; SERUM, PLASMA OR WHOLE BLOOD" 3018415501_1 CDM 301 RC 84155 HCPCS outpatient 71 53.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 63.19 89 999999999 55.38 67.45 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; SERUM, PLASMA OR WHOLE BLOOD" 3018415501_1 CDM 301 RC 84155 HCPCS outpatient 71 53.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 62.48 88 999999999 55.38 67.45 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; SERUM, PLASMA OR WHOLE BLOOD" 3018415501_1 CDM 301 RC 84155 HCPCS outpatient 71 53.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 63.19 89 999999999 55.38 67.45 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; URINE" 3018415601_1 CDM 301 RC 84156 HCPCS outpatient 78 58.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 70.2 90 999999999 60.84 74.1 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; URINE" 3018415601_1 CDM 301 RC 84156 HCPCS outpatient 78 58.5 AETNA MCR ADV AETNA MCR ADV 60.84 78 999999999 60.84 74.1 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; URINE" 3018415601_1 CDM 301 RC 84156 HCPCS outpatient 78 58.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 68.3 87.57 999999999 60.84 74.1 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; URINE" 3018415601_1 CDM 301 RC 84156 HCPCS outpatient 78 58.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 66.35 85.07 999999999 60.84 74.1 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; URINE" 3018415601_1 CDM 301 RC 84156 HCPCS outpatient 78 58.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 66.35 85.07 999999999 60.84 74.1 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; URINE" 3018415601_1 CDM 301 RC 84156 HCPCS outpatient 78 58.5 MOLINA MCAID MOLINA MCAID 65.05 83.4 999999999 60.84 74.1 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; URINE" 3018415601_1 CDM 301 RC 84156 HCPCS outpatient 78 58.5 MOLINA MCR ADV MOLINA MCR ADV 69.42 89 999999999 60.84 74.1 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; URINE" 3018415601_1 CDM 301 RC 84156 HCPCS outpatient 78 58.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 69.42 89 999999999 60.84 74.1 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; URINE" 3018415601_1 CDM 301 RC 84156 HCPCS outpatient 78 58.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 69.42 89 999999999 60.84 74.1 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; URINE" 3018415601_1 CDM 301 RC 84156 HCPCS outpatient 78 58.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 70.2 90 999999999 60.84 74.1 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; URINE" 3018415601_1 CDM 301 RC 84156 HCPCS outpatient 78 58.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 74.1 95 999999999 60.84 74.1 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; URINE" 3018415601_1 CDM 301 RC 84156 HCPCS outpatient 78 58.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 74.1 95 999999999 60.84 74.1 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; URINE" 3018415601_1 CDM 301 RC 84156 HCPCS outpatient 78 58.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 69.42 89 999999999 60.84 74.1 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; URINE" 3018415601_1 CDM 301 RC 84156 HCPCS outpatient 78 58.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 68.64 88 999999999 60.84 74.1 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; URINE" 3018415601_1 CDM 301 RC 84156 HCPCS outpatient 78 58.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 69.42 89 999999999 60.84 74.1 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; OTHER SOURCE (EG, SYNOVIAL FLUID, CEREBROSPINAL FLUID)" 3018415702_1 CDM 301 RC 84157 HCPCS outpatient 72 54 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 64.8 90 999999999 56.16 68.4 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; OTHER SOURCE (EG, SYNOVIAL FLUID, CEREBROSPINAL FLUID)" 3018415702_1 CDM 301 RC 84157 HCPCS outpatient 72 54 AETNA MCR ADV AETNA MCR ADV 56.16 78 999999999 56.16 68.4 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; OTHER SOURCE (EG, SYNOVIAL FLUID, CEREBROSPINAL FLUID)" 3018415702_1 CDM 301 RC 84157 HCPCS outpatient 72 54 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 63.05 87.57 999999999 56.16 68.4 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; OTHER SOURCE (EG, SYNOVIAL FLUID, CEREBROSPINAL FLUID)" 3018415702_1 CDM 301 RC 84157 HCPCS outpatient 72 54 COORDINATED CARE MCAID COORDINATED CARE MCAID 61.25 85.07 999999999 56.16 68.4 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; OTHER SOURCE (EG, SYNOVIAL FLUID, CEREBROSPINAL FLUID)" 3018415702_1 CDM 301 RC 84157 HCPCS outpatient 72 54 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 61.25 85.07 999999999 56.16 68.4 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; OTHER SOURCE (EG, SYNOVIAL FLUID, CEREBROSPINAL FLUID)" 3018415702_1 CDM 301 RC 84157 HCPCS outpatient 72 54 MOLINA MCAID MOLINA MCAID 60.05 83.4 999999999 56.16 68.4 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; OTHER SOURCE (EG, SYNOVIAL FLUID, CEREBROSPINAL FLUID)" 3018415702_1 CDM 301 RC 84157 HCPCS outpatient 72 54 MOLINA MCR ADV MOLINA MCR ADV 64.08 89 999999999 56.16 68.4 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; OTHER SOURCE (EG, SYNOVIAL FLUID, CEREBROSPINAL FLUID)" 3018415702_1 CDM 301 RC 84157 HCPCS outpatient 72 54 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 64.08 89 999999999 56.16 68.4 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; OTHER SOURCE (EG, SYNOVIAL FLUID, CEREBROSPINAL FLUID)" 3018415702_1 CDM 301 RC 84157 HCPCS outpatient 72 54 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 64.08 89 999999999 56.16 68.4 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; OTHER SOURCE (EG, SYNOVIAL FLUID, CEREBROSPINAL FLUID)" 3018415702_1 CDM 301 RC 84157 HCPCS outpatient 72 54 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 64.8 90 999999999 56.16 68.4 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; OTHER SOURCE (EG, SYNOVIAL FLUID, CEREBROSPINAL FLUID)" 3018415702_1 CDM 301 RC 84157 HCPCS outpatient 72 54 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 68.4 95 999999999 56.16 68.4 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; OTHER SOURCE (EG, SYNOVIAL FLUID, CEREBROSPINAL FLUID)" 3018415702_1 CDM 301 RC 84157 HCPCS outpatient 72 54 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 68.4 95 999999999 56.16 68.4 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; OTHER SOURCE (EG, SYNOVIAL FLUID, CEREBROSPINAL FLUID)" 3018415702_1 CDM 301 RC 84157 HCPCS outpatient 72 54 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 64.08 89 999999999 56.16 68.4 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; OTHER SOURCE (EG, SYNOVIAL FLUID, CEREBROSPINAL FLUID)" 3018415702_1 CDM 301 RC 84157 HCPCS outpatient 72 54 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 63.36 88 999999999 56.16 68.4 percent of total billed charges "PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; OTHER SOURCE (EG, SYNOVIAL FLUID, CEREBROSPINAL FLUID)" 3018415702_1 CDM 301 RC 84157 HCPCS outpatient 72 54 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 64.08 89 999999999 56.16 68.4 percent of total billed charges "PROTEIN; ELECTROPHORETIC FRACTIONATION AND QUANTITATION, SERUM" 3018416501_1 CDM 301 RC 84165 HCPCS outpatient 142 106.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 127.8 90 999999999 110.76 134.9 percent of total billed charges "PROTEIN; ELECTROPHORETIC FRACTIONATION AND QUANTITATION, SERUM" 3018416501_1 CDM 301 RC 84165 HCPCS outpatient 142 106.5 AETNA MCR ADV AETNA MCR ADV 110.76 78 999999999 110.76 134.9 percent of total billed charges "PROTEIN; ELECTROPHORETIC FRACTIONATION AND QUANTITATION, SERUM" 3018416501_1 CDM 301 RC 84165 HCPCS outpatient 142 106.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 124.35 87.57 999999999 110.76 134.9 percent of total billed charges "PROTEIN; ELECTROPHORETIC FRACTIONATION AND QUANTITATION, SERUM" 3018416501_1 CDM 301 RC 84165 HCPCS outpatient 142 106.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 120.8 85.07 999999999 110.76 134.9 percent of total billed charges "PROTEIN; ELECTROPHORETIC FRACTIONATION AND QUANTITATION, SERUM" 3018416501_1 CDM 301 RC 84165 HCPCS outpatient 142 106.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 120.8 85.07 999999999 110.76 134.9 percent of total billed charges "PROTEIN; ELECTROPHORETIC FRACTIONATION AND QUANTITATION, SERUM" 3018416501_1 CDM 301 RC 84165 HCPCS outpatient 142 106.5 MOLINA MCAID MOLINA MCAID 118.43 83.4 999999999 110.76 134.9 percent of total billed charges "PROTEIN; ELECTROPHORETIC FRACTIONATION AND QUANTITATION, SERUM" 3018416501_1 CDM 301 RC 84165 HCPCS outpatient 142 106.5 MOLINA MCR ADV MOLINA MCR ADV 126.38 89 999999999 110.76 134.9 percent of total billed charges "PROTEIN; ELECTROPHORETIC FRACTIONATION AND QUANTITATION, SERUM" 3018416501_1 CDM 301 RC 84165 HCPCS outpatient 142 106.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 126.38 89 999999999 110.76 134.9 percent of total billed charges "PROTEIN; ELECTROPHORETIC FRACTIONATION AND QUANTITATION, SERUM" 3018416501_1 CDM 301 RC 84165 HCPCS outpatient 142 106.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 126.38 89 999999999 110.76 134.9 percent of total billed charges "PROTEIN; ELECTROPHORETIC FRACTIONATION AND QUANTITATION, SERUM" 3018416501_1 CDM 301 RC 84165 HCPCS outpatient 142 106.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 127.8 90 999999999 110.76 134.9 percent of total billed charges "PROTEIN; ELECTROPHORETIC FRACTIONATION AND QUANTITATION, SERUM" 3018416501_1 CDM 301 RC 84165 HCPCS outpatient 142 106.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 134.9 95 999999999 110.76 134.9 percent of total billed charges "PROTEIN; ELECTROPHORETIC FRACTIONATION AND QUANTITATION, SERUM" 3018416501_1 CDM 301 RC 84165 HCPCS outpatient 142 106.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 134.9 95 999999999 110.76 134.9 percent of total billed charges "PROTEIN; ELECTROPHORETIC FRACTIONATION AND QUANTITATION, SERUM" 3018416501_1 CDM 301 RC 84165 HCPCS outpatient 142 106.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 126.38 89 999999999 110.76 134.9 percent of total billed charges "PROTEIN; ELECTROPHORETIC FRACTIONATION AND QUANTITATION, SERUM" 3018416501_1 CDM 301 RC 84165 HCPCS outpatient 142 106.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 124.96 88 999999999 110.76 134.9 percent of total billed charges "PROTEIN; ELECTROPHORETIC FRACTIONATION AND QUANTITATION, SERUM" 3018416501_1 CDM 301 RC 84165 HCPCS outpatient 142 106.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 126.38 89 999999999 110.76 134.9 percent of total billed charges "PROTEIN; ELECTROPHORETIC FRACTIONATION AND QUANTITATION, OTHER FLUIDS WITH CONCENTRATION (EG, URINE, CSF)" 3018416601_1 CDM 301 RC 84166 HCPCS outpatient 160 120 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 144 90 999999999 124.8 152 percent of total billed charges "PROTEIN; ELECTROPHORETIC FRACTIONATION AND QUANTITATION, OTHER FLUIDS WITH CONCENTRATION (EG, URINE, CSF)" 3018416601_1 CDM 301 RC 84166 HCPCS outpatient 160 120 AETNA MCR ADV AETNA MCR ADV 124.8 78 999999999 124.8 152 percent of total billed charges "PROTEIN; ELECTROPHORETIC FRACTIONATION AND QUANTITATION, OTHER FLUIDS WITH CONCENTRATION (EG, URINE, CSF)" 3018416601_1 CDM 301 RC 84166 HCPCS outpatient 160 120 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 140.11 87.57 999999999 124.8 152 percent of total billed charges "PROTEIN; ELECTROPHORETIC FRACTIONATION AND QUANTITATION, OTHER FLUIDS WITH CONCENTRATION (EG, URINE, CSF)" 3018416601_1 CDM 301 RC 84166 HCPCS outpatient 160 120 COORDINATED CARE MCAID COORDINATED CARE MCAID 136.11 85.07 999999999 124.8 152 percent of total billed charges "PROTEIN; ELECTROPHORETIC FRACTIONATION AND QUANTITATION, OTHER FLUIDS WITH CONCENTRATION (EG, URINE, CSF)" 3018416601_1 CDM 301 RC 84166 HCPCS outpatient 160 120 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 136.11 85.07 999999999 124.8 152 percent of total billed charges "PROTEIN; ELECTROPHORETIC FRACTIONATION AND QUANTITATION, OTHER FLUIDS WITH CONCENTRATION (EG, URINE, CSF)" 3018416601_1 CDM 301 RC 84166 HCPCS outpatient 160 120 MOLINA MCAID MOLINA MCAID 133.44 83.4 999999999 124.8 152 percent of total billed charges "PROTEIN; ELECTROPHORETIC FRACTIONATION AND QUANTITATION, OTHER FLUIDS WITH CONCENTRATION (EG, URINE, CSF)" 3018416601_1 CDM 301 RC 84166 HCPCS outpatient 160 120 MOLINA MCR ADV MOLINA MCR ADV 142.4 89 999999999 124.8 152 percent of total billed charges "PROTEIN; ELECTROPHORETIC FRACTIONATION AND QUANTITATION, OTHER FLUIDS WITH CONCENTRATION (EG, URINE, CSF)" 3018416601_1 CDM 301 RC 84166 HCPCS outpatient 160 120 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 142.4 89 999999999 124.8 152 percent of total billed charges "PROTEIN; ELECTROPHORETIC FRACTIONATION AND QUANTITATION, OTHER FLUIDS WITH CONCENTRATION (EG, URINE, CSF)" 3018416601_1 CDM 301 RC 84166 HCPCS outpatient 160 120 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 142.4 89 999999999 124.8 152 percent of total billed charges "PROTEIN; ELECTROPHORETIC FRACTIONATION AND QUANTITATION, OTHER FLUIDS WITH CONCENTRATION (EG, URINE, CSF)" 3018416601_1 CDM 301 RC 84166 HCPCS outpatient 160 120 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 144 90 999999999 124.8 152 percent of total billed charges "PROTEIN; ELECTROPHORETIC FRACTIONATION AND QUANTITATION, OTHER FLUIDS WITH CONCENTRATION (EG, URINE, CSF)" 3018416601_1 CDM 301 RC 84166 HCPCS outpatient 160 120 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 152 95 999999999 124.8 152 percent of total billed charges "PROTEIN; ELECTROPHORETIC FRACTIONATION AND QUANTITATION, OTHER FLUIDS WITH CONCENTRATION (EG, URINE, CSF)" 3018416601_1 CDM 301 RC 84166 HCPCS outpatient 160 120 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 152 95 999999999 124.8 152 percent of total billed charges "PROTEIN; ELECTROPHORETIC FRACTIONATION AND QUANTITATION, OTHER FLUIDS WITH CONCENTRATION (EG, URINE, CSF)" 3018416601_1 CDM 301 RC 84166 HCPCS outpatient 160 120 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 142.4 89 999999999 124.8 152 percent of total billed charges "PROTEIN; ELECTROPHORETIC FRACTIONATION AND QUANTITATION, OTHER FLUIDS WITH CONCENTRATION (EG, URINE, CSF)" 3018416601_1 CDM 301 RC 84166 HCPCS outpatient 160 120 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 140.8 88 999999999 124.8 152 percent of total billed charges "PROTEIN; ELECTROPHORETIC FRACTIONATION AND QUANTITATION, OTHER FLUIDS WITH CONCENTRATION (EG, URINE, CSF)" 3018416601_1 CDM 301 RC 84166 HCPCS outpatient 160 120 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 142.4 89 999999999 124.8 152 percent of total billed charges SEROTONIN 3018426001_1 CDM 301 RC 84260 HCPCS outpatient 174 130.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 156.6 90 999999999 135.72 165.3 percent of total billed charges SEROTONIN 3018426001_1 CDM 301 RC 84260 HCPCS outpatient 174 130.5 AETNA MCR ADV AETNA MCR ADV 135.72 78 999999999 135.72 165.3 percent of total billed charges SEROTONIN 3018426001_1 CDM 301 RC 84260 HCPCS outpatient 174 130.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 152.37 87.57 999999999 135.72 165.3 percent of total billed charges SEROTONIN 3018426001_1 CDM 301 RC 84260 HCPCS outpatient 174 130.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 148.02 85.07 999999999 135.72 165.3 percent of total billed charges SEROTONIN 3018426001_1 CDM 301 RC 84260 HCPCS outpatient 174 130.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 148.02 85.07 999999999 135.72 165.3 percent of total billed charges SEROTONIN 3018426001_1 CDM 301 RC 84260 HCPCS outpatient 174 130.5 MOLINA MCAID MOLINA MCAID 145.12 83.4 999999999 135.72 165.3 percent of total billed charges SEROTONIN 3018426001_1 CDM 301 RC 84260 HCPCS outpatient 174 130.5 MOLINA MCR ADV MOLINA MCR ADV 154.86 89 999999999 135.72 165.3 percent of total billed charges SEROTONIN 3018426001_1 CDM 301 RC 84260 HCPCS outpatient 174 130.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 154.86 89 999999999 135.72 165.3 percent of total billed charges SEROTONIN 3018426001_1 CDM 301 RC 84260 HCPCS outpatient 174 130.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 154.86 89 999999999 135.72 165.3 percent of total billed charges SEROTONIN 3018426001_1 CDM 301 RC 84260 HCPCS outpatient 174 130.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 156.6 90 999999999 135.72 165.3 percent of total billed charges SEROTONIN 3018426001_1 CDM 301 RC 84260 HCPCS outpatient 174 130.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 165.3 95 999999999 135.72 165.3 percent of total billed charges SEROTONIN 3018426001_1 CDM 301 RC 84260 HCPCS outpatient 174 130.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 165.3 95 999999999 135.72 165.3 percent of total billed charges SEROTONIN 3018426001_1 CDM 301 RC 84260 HCPCS outpatient 174 130.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 154.86 89 999999999 135.72 165.3 percent of total billed charges SEROTONIN 3018426001_1 CDM 301 RC 84260 HCPCS outpatient 174 130.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 153.12 88 999999999 135.72 165.3 percent of total billed charges SEROTONIN 3018426001_1 CDM 301 RC 84260 HCPCS outpatient 174 130.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 154.86 89 999999999 135.72 165.3 percent of total billed charges "SODIUM; SERUM, PLASMA OR WHOLE BLOOD" 3018429501_1 CDM 301 RC 84295 HCPCS outpatient 51 38.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 45.9 90 999999999 39.78 48.45 percent of total billed charges "SODIUM; SERUM, PLASMA OR WHOLE BLOOD" 3018429501_1 CDM 301 RC 84295 HCPCS outpatient 51 38.25 AETNA MCR ADV AETNA MCR ADV 39.78 78 999999999 39.78 48.45 percent of total billed charges "SODIUM; SERUM, PLASMA OR WHOLE BLOOD" 3018429501_1 CDM 301 RC 84295 HCPCS outpatient 51 38.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 44.66 87.57 999999999 39.78 48.45 percent of total billed charges "SODIUM; SERUM, PLASMA OR WHOLE BLOOD" 3018429501_1 CDM 301 RC 84295 HCPCS outpatient 51 38.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 43.39 85.07 999999999 39.78 48.45 percent of total billed charges "SODIUM; SERUM, PLASMA OR WHOLE BLOOD" 3018429501_1 CDM 301 RC 84295 HCPCS outpatient 51 38.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 43.39 85.07 999999999 39.78 48.45 percent of total billed charges "SODIUM; SERUM, PLASMA OR WHOLE BLOOD" 3018429501_1 CDM 301 RC 84295 HCPCS outpatient 51 38.25 MOLINA MCAID MOLINA MCAID 42.53 83.4 999999999 39.78 48.45 percent of total billed charges "SODIUM; SERUM, PLASMA OR WHOLE BLOOD" 3018429501_1 CDM 301 RC 84295 HCPCS outpatient 51 38.25 MOLINA MCR ADV MOLINA MCR ADV 45.39 89 999999999 39.78 48.45 percent of total billed charges "SODIUM; SERUM, PLASMA OR WHOLE BLOOD" 3018429501_1 CDM 301 RC 84295 HCPCS outpatient 51 38.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 45.39 89 999999999 39.78 48.45 percent of total billed charges "SODIUM; SERUM, PLASMA OR WHOLE BLOOD" 3018429501_1 CDM 301 RC 84295 HCPCS outpatient 51 38.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 45.39 89 999999999 39.78 48.45 percent of total billed charges "SODIUM; SERUM, PLASMA OR WHOLE BLOOD" 3018429501_1 CDM 301 RC 84295 HCPCS outpatient 51 38.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 45.9 90 999999999 39.78 48.45 percent of total billed charges "SODIUM; SERUM, PLASMA OR WHOLE BLOOD" 3018429501_1 CDM 301 RC 84295 HCPCS outpatient 51 38.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 48.45 95 999999999 39.78 48.45 percent of total billed charges "SODIUM; SERUM, PLASMA OR WHOLE BLOOD" 3018429501_1 CDM 301 RC 84295 HCPCS outpatient 51 38.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 48.45 95 999999999 39.78 48.45 percent of total billed charges "SODIUM; SERUM, PLASMA OR WHOLE BLOOD" 3018429501_1 CDM 301 RC 84295 HCPCS outpatient 51 38.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 45.39 89 999999999 39.78 48.45 percent of total billed charges "SODIUM; SERUM, PLASMA OR WHOLE BLOOD" 3018429501_1 CDM 301 RC 84295 HCPCS outpatient 51 38.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 44.88 88 999999999 39.78 48.45 percent of total billed charges "SODIUM; SERUM, PLASMA OR WHOLE BLOOD" 3018429501_1 CDM 301 RC 84295 HCPCS outpatient 51 38.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 45.39 89 999999999 39.78 48.45 percent of total billed charges SODIUM; URINE 3018430001_1 CDM 301 RC 84300 HCPCS outpatient 68 51 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 61.2 90 999999999 53.04 64.6 percent of total billed charges SODIUM; URINE 3018430001_1 CDM 301 RC 84300 HCPCS outpatient 68 51 AETNA MCR ADV AETNA MCR ADV 53.04 78 999999999 53.04 64.6 percent of total billed charges SODIUM; URINE 3018430001_1 CDM 301 RC 84300 HCPCS outpatient 68 51 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 59.55 87.57 999999999 53.04 64.6 percent of total billed charges SODIUM; URINE 3018430001_1 CDM 301 RC 84300 HCPCS outpatient 68 51 COORDINATED CARE MCAID COORDINATED CARE MCAID 57.85 85.07 999999999 53.04 64.6 percent of total billed charges SODIUM; URINE 3018430001_1 CDM 301 RC 84300 HCPCS outpatient 68 51 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 57.85 85.07 999999999 53.04 64.6 percent of total billed charges SODIUM; URINE 3018430001_1 CDM 301 RC 84300 HCPCS outpatient 68 51 MOLINA MCAID MOLINA MCAID 56.71 83.4 999999999 53.04 64.6 percent of total billed charges SODIUM; URINE 3018430001_1 CDM 301 RC 84300 HCPCS outpatient 68 51 MOLINA MCR ADV MOLINA MCR ADV 60.52 89 999999999 53.04 64.6 percent of total billed charges SODIUM; URINE 3018430001_1 CDM 301 RC 84300 HCPCS outpatient 68 51 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 60.52 89 999999999 53.04 64.6 percent of total billed charges SODIUM; URINE 3018430001_1 CDM 301 RC 84300 HCPCS outpatient 68 51 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 60.52 89 999999999 53.04 64.6 percent of total billed charges SODIUM; URINE 3018430001_1 CDM 301 RC 84300 HCPCS outpatient 68 51 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 61.2 90 999999999 53.04 64.6 percent of total billed charges SODIUM; URINE 3018430001_1 CDM 301 RC 84300 HCPCS outpatient 68 51 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 64.6 95 999999999 53.04 64.6 percent of total billed charges SODIUM; URINE 3018430001_1 CDM 301 RC 84300 HCPCS outpatient 68 51 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 64.6 95 999999999 53.04 64.6 percent of total billed charges SODIUM; URINE 3018430001_1 CDM 301 RC 84300 HCPCS outpatient 68 51 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 60.52 89 999999999 53.04 64.6 percent of total billed charges SODIUM; URINE 3018430001_1 CDM 301 RC 84300 HCPCS outpatient 68 51 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 59.84 88 999999999 53.04 64.6 percent of total billed charges SODIUM; URINE 3018430001_1 CDM 301 RC 84300 HCPCS outpatient 68 51 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 60.52 89 999999999 53.04 64.6 percent of total billed charges TESTOSTERONE; FREE 3018440202_1 CDM 301 RC 84402 HCPCS outpatient 152 114 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 136.8 90 999999999 118.56 144.4 percent of total billed charges TESTOSTERONE; FREE 3018440202_1 CDM 301 RC 84402 HCPCS outpatient 152 114 AETNA MCR ADV AETNA MCR ADV 118.56 78 999999999 118.56 144.4 percent of total billed charges TESTOSTERONE; FREE 3018440202_1 CDM 301 RC 84402 HCPCS outpatient 152 114 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 133.11 87.57 999999999 118.56 144.4 percent of total billed charges TESTOSTERONE; FREE 3018440202_1 CDM 301 RC 84402 HCPCS outpatient 152 114 COORDINATED CARE MCAID COORDINATED CARE MCAID 129.31 85.07 999999999 118.56 144.4 percent of total billed charges TESTOSTERONE; FREE 3018440202_1 CDM 301 RC 84402 HCPCS outpatient 152 114 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 129.31 85.07 999999999 118.56 144.4 percent of total billed charges TESTOSTERONE; FREE 3018440202_1 CDM 301 RC 84402 HCPCS outpatient 152 114 MOLINA MCAID MOLINA MCAID 126.77 83.4 999999999 118.56 144.4 percent of total billed charges TESTOSTERONE; FREE 3018440202_1 CDM 301 RC 84402 HCPCS outpatient 152 114 MOLINA MCR ADV MOLINA MCR ADV 135.28 89 999999999 118.56 144.4 percent of total billed charges TESTOSTERONE; FREE 3018440202_1 CDM 301 RC 84402 HCPCS outpatient 152 114 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 135.28 89 999999999 118.56 144.4 percent of total billed charges TESTOSTERONE; FREE 3018440202_1 CDM 301 RC 84402 HCPCS outpatient 152 114 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 135.28 89 999999999 118.56 144.4 percent of total billed charges TESTOSTERONE; FREE 3018440202_1 CDM 301 RC 84402 HCPCS outpatient 152 114 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 136.8 90 999999999 118.56 144.4 percent of total billed charges TESTOSTERONE; FREE 3018440202_1 CDM 301 RC 84402 HCPCS outpatient 152 114 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 144.4 95 999999999 118.56 144.4 percent of total billed charges TESTOSTERONE; FREE 3018440202_1 CDM 301 RC 84402 HCPCS outpatient 152 114 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 144.4 95 999999999 118.56 144.4 percent of total billed charges TESTOSTERONE; FREE 3018440202_1 CDM 301 RC 84402 HCPCS outpatient 152 114 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 135.28 89 999999999 118.56 144.4 percent of total billed charges TESTOSTERONE; FREE 3018440202_1 CDM 301 RC 84402 HCPCS outpatient 152 114 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 133.76 88 999999999 118.56 144.4 percent of total billed charges TESTOSTERONE; FREE 3018440202_1 CDM 301 RC 84402 HCPCS outpatient 152 114 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 135.28 89 999999999 118.56 144.4 percent of total billed charges TESTOSTERONE; TOTAL 3018440301_1 CDM 301 RC 84403 HCPCS outpatient 96 72 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 86.4 90 999999999 74.88 91.2 percent of total billed charges TESTOSTERONE; TOTAL 3018440301_1 CDM 301 RC 84403 HCPCS outpatient 96 72 AETNA MCR ADV AETNA MCR ADV 74.88 78 999999999 74.88 91.2 percent of total billed charges TESTOSTERONE; TOTAL 3018440301_1 CDM 301 RC 84403 HCPCS outpatient 96 72 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 84.07 87.57 999999999 74.88 91.2 percent of total billed charges TESTOSTERONE; TOTAL 3018440301_1 CDM 301 RC 84403 HCPCS outpatient 96 72 COORDINATED CARE MCAID COORDINATED CARE MCAID 81.67 85.07 999999999 74.88 91.2 percent of total billed charges TESTOSTERONE; TOTAL 3018440301_1 CDM 301 RC 84403 HCPCS outpatient 96 72 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 81.67 85.07 999999999 74.88 91.2 percent of total billed charges TESTOSTERONE; TOTAL 3018440301_1 CDM 301 RC 84403 HCPCS outpatient 96 72 MOLINA MCAID MOLINA MCAID 80.06 83.4 999999999 74.88 91.2 percent of total billed charges TESTOSTERONE; TOTAL 3018440301_1 CDM 301 RC 84403 HCPCS outpatient 96 72 MOLINA MCR ADV MOLINA MCR ADV 85.44 89 999999999 74.88 91.2 percent of total billed charges TESTOSTERONE; TOTAL 3018440301_1 CDM 301 RC 84403 HCPCS outpatient 96 72 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 85.44 89 999999999 74.88 91.2 percent of total billed charges TESTOSTERONE; TOTAL 3018440301_1 CDM 301 RC 84403 HCPCS outpatient 96 72 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 85.44 89 999999999 74.88 91.2 percent of total billed charges TESTOSTERONE; TOTAL 3018440301_1 CDM 301 RC 84403 HCPCS outpatient 96 72 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 86.4 90 999999999 74.88 91.2 percent of total billed charges TESTOSTERONE; TOTAL 3018440301_1 CDM 301 RC 84403 HCPCS outpatient 96 72 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 91.2 95 999999999 74.88 91.2 percent of total billed charges TESTOSTERONE; TOTAL 3018440301_1 CDM 301 RC 84403 HCPCS outpatient 96 72 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 91.2 95 999999999 74.88 91.2 percent of total billed charges TESTOSTERONE; TOTAL 3018440301_1 CDM 301 RC 84403 HCPCS outpatient 96 72 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 85.44 89 999999999 74.88 91.2 percent of total billed charges TESTOSTERONE; TOTAL 3018440301_1 CDM 301 RC 84403 HCPCS outpatient 96 72 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 84.48 88 999999999 74.88 91.2 percent of total billed charges TESTOSTERONE; TOTAL 3018440301_1 CDM 301 RC 84403 HCPCS outpatient 96 72 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 85.44 89 999999999 74.88 91.2 percent of total billed charges TESTOSTERONE; TOTAL 3018440303_1 CDM 301 RC 84403 HCPCS outpatient 96 72 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 86.4 90 999999999 74.88 91.2 percent of total billed charges TESTOSTERONE; TOTAL 3018440303_1 CDM 301 RC 84403 HCPCS outpatient 96 72 AETNA MCR ADV AETNA MCR ADV 74.88 78 999999999 74.88 91.2 percent of total billed charges TESTOSTERONE; TOTAL 3018440303_1 CDM 301 RC 84403 HCPCS outpatient 96 72 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 84.07 87.57 999999999 74.88 91.2 percent of total billed charges TESTOSTERONE; TOTAL 3018440303_1 CDM 301 RC 84403 HCPCS outpatient 96 72 COORDINATED CARE MCAID COORDINATED CARE MCAID 81.67 85.07 999999999 74.88 91.2 percent of total billed charges TESTOSTERONE; TOTAL 3018440303_1 CDM 301 RC 84403 HCPCS outpatient 96 72 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 81.67 85.07 999999999 74.88 91.2 percent of total billed charges TESTOSTERONE; TOTAL 3018440303_1 CDM 301 RC 84403 HCPCS outpatient 96 72 MOLINA MCAID MOLINA MCAID 80.06 83.4 999999999 74.88 91.2 percent of total billed charges TESTOSTERONE; TOTAL 3018440303_1 CDM 301 RC 84403 HCPCS outpatient 96 72 MOLINA MCR ADV MOLINA MCR ADV 85.44 89 999999999 74.88 91.2 percent of total billed charges TESTOSTERONE; TOTAL 3018440303_1 CDM 301 RC 84403 HCPCS outpatient 96 72 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 85.44 89 999999999 74.88 91.2 percent of total billed charges TESTOSTERONE; TOTAL 3018440303_1 CDM 301 RC 84403 HCPCS outpatient 96 72 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 85.44 89 999999999 74.88 91.2 percent of total billed charges TESTOSTERONE; TOTAL 3018440303_1 CDM 301 RC 84403 HCPCS outpatient 96 72 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 86.4 90 999999999 74.88 91.2 percent of total billed charges TESTOSTERONE; TOTAL 3018440303_1 CDM 301 RC 84403 HCPCS outpatient 96 72 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 91.2 95 999999999 74.88 91.2 percent of total billed charges TESTOSTERONE; TOTAL 3018440303_1 CDM 301 RC 84403 HCPCS outpatient 96 72 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 91.2 95 999999999 74.88 91.2 percent of total billed charges TESTOSTERONE; TOTAL 3018440303_1 CDM 301 RC 84403 HCPCS outpatient 96 72 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 85.44 89 999999999 74.88 91.2 percent of total billed charges TESTOSTERONE; TOTAL 3018440303_1 CDM 301 RC 84403 HCPCS outpatient 96 72 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 84.48 88 999999999 74.88 91.2 percent of total billed charges TESTOSTERONE; TOTAL 3018440303_1 CDM 301 RC 84403 HCPCS outpatient 96 72 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 85.44 89 999999999 74.88 91.2 percent of total billed charges THIAMINE (VITAMIN B-1) 3018442501_1 CDM 301 RC 84425 HCPCS outpatient 146 109.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 131.4 90 999999999 113.88 138.7 percent of total billed charges THIAMINE (VITAMIN B-1) 3018442501_1 CDM 301 RC 84425 HCPCS outpatient 146 109.5 AETNA MCR ADV AETNA MCR ADV 113.88 78 999999999 113.88 138.7 percent of total billed charges THIAMINE (VITAMIN B-1) 3018442501_1 CDM 301 RC 84425 HCPCS outpatient 146 109.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 127.85 87.57 999999999 113.88 138.7 percent of total billed charges THIAMINE (VITAMIN B-1) 3018442501_1 CDM 301 RC 84425 HCPCS outpatient 146 109.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 124.2 85.07 999999999 113.88 138.7 percent of total billed charges THIAMINE (VITAMIN B-1) 3018442501_1 CDM 301 RC 84425 HCPCS outpatient 146 109.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 124.2 85.07 999999999 113.88 138.7 percent of total billed charges THIAMINE (VITAMIN B-1) 3018442501_1 CDM 301 RC 84425 HCPCS outpatient 146 109.5 MOLINA MCAID MOLINA MCAID 121.76 83.4 999999999 113.88 138.7 percent of total billed charges THIAMINE (VITAMIN B-1) 3018442501_1 CDM 301 RC 84425 HCPCS outpatient 146 109.5 MOLINA MCR ADV MOLINA MCR ADV 129.94 89 999999999 113.88 138.7 percent of total billed charges THIAMINE (VITAMIN B-1) 3018442501_1 CDM 301 RC 84425 HCPCS outpatient 146 109.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 129.94 89 999999999 113.88 138.7 percent of total billed charges THIAMINE (VITAMIN B-1) 3018442501_1 CDM 301 RC 84425 HCPCS outpatient 146 109.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 129.94 89 999999999 113.88 138.7 percent of total billed charges THIAMINE (VITAMIN B-1) 3018442501_1 CDM 301 RC 84425 HCPCS outpatient 146 109.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 131.4 90 999999999 113.88 138.7 percent of total billed charges THIAMINE (VITAMIN B-1) 3018442501_1 CDM 301 RC 84425 HCPCS outpatient 146 109.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 138.7 95 999999999 113.88 138.7 percent of total billed charges THIAMINE (VITAMIN B-1) 3018442501_1 CDM 301 RC 84425 HCPCS outpatient 146 109.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 138.7 95 999999999 113.88 138.7 percent of total billed charges THIAMINE (VITAMIN B-1) 3018442501_1 CDM 301 RC 84425 HCPCS outpatient 146 109.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 129.94 89 999999999 113.88 138.7 percent of total billed charges THIAMINE (VITAMIN B-1) 3018442501_1 CDM 301 RC 84425 HCPCS outpatient 146 109.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 128.48 88 999999999 113.88 138.7 percent of total billed charges THIAMINE (VITAMIN B-1) 3018442501_1 CDM 301 RC 84425 HCPCS outpatient 146 109.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 129.94 89 999999999 113.88 138.7 percent of total billed charges THYROXINE; TOTAL 3018443601_1 CDM 301 RC 84436 HCPCS outpatient 68 51 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 61.2 90 999999999 53.04 64.6 percent of total billed charges THYROXINE; TOTAL 3018443601_1 CDM 301 RC 84436 HCPCS outpatient 68 51 AETNA MCR ADV AETNA MCR ADV 53.04 78 999999999 53.04 64.6 percent of total billed charges THYROXINE; TOTAL 3018443601_1 CDM 301 RC 84436 HCPCS outpatient 68 51 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 59.55 87.57 999999999 53.04 64.6 percent of total billed charges THYROXINE; TOTAL 3018443601_1 CDM 301 RC 84436 HCPCS outpatient 68 51 COORDINATED CARE MCAID COORDINATED CARE MCAID 57.85 85.07 999999999 53.04 64.6 percent of total billed charges THYROXINE; TOTAL 3018443601_1 CDM 301 RC 84436 HCPCS outpatient 68 51 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 57.85 85.07 999999999 53.04 64.6 percent of total billed charges THYROXINE; TOTAL 3018443601_1 CDM 301 RC 84436 HCPCS outpatient 68 51 MOLINA MCAID MOLINA MCAID 56.71 83.4 999999999 53.04 64.6 percent of total billed charges THYROXINE; TOTAL 3018443601_1 CDM 301 RC 84436 HCPCS outpatient 68 51 MOLINA MCR ADV MOLINA MCR ADV 60.52 89 999999999 53.04 64.6 percent of total billed charges THYROXINE; TOTAL 3018443601_1 CDM 301 RC 84436 HCPCS outpatient 68 51 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 60.52 89 999999999 53.04 64.6 percent of total billed charges THYROXINE; TOTAL 3018443601_1 CDM 301 RC 84436 HCPCS outpatient 68 51 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 60.52 89 999999999 53.04 64.6 percent of total billed charges THYROXINE; TOTAL 3018443601_1 CDM 301 RC 84436 HCPCS outpatient 68 51 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 61.2 90 999999999 53.04 64.6 percent of total billed charges THYROXINE; TOTAL 3018443601_1 CDM 301 RC 84436 HCPCS outpatient 68 51 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 64.6 95 999999999 53.04 64.6 percent of total billed charges THYROXINE; TOTAL 3018443601_1 CDM 301 RC 84436 HCPCS outpatient 68 51 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 64.6 95 999999999 53.04 64.6 percent of total billed charges THYROXINE; TOTAL 3018443601_1 CDM 301 RC 84436 HCPCS outpatient 68 51 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 60.52 89 999999999 53.04 64.6 percent of total billed charges THYROXINE; TOTAL 3018443601_1 CDM 301 RC 84436 HCPCS outpatient 68 51 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 59.84 88 999999999 53.04 64.6 percent of total billed charges THYROXINE; TOTAL 3018443601_1 CDM 301 RC 84436 HCPCS outpatient 68 51 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 60.52 89 999999999 53.04 64.6 percent of total billed charges THYROXINE; FREE 3018443901_1 CDM 301 RC 84439 HCPCS outpatient 109 81.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 98.1 90 999999999 85.02 103.55 percent of total billed charges THYROXINE; FREE 3018443901_1 CDM 301 RC 84439 HCPCS outpatient 109 81.75 AETNA MCR ADV AETNA MCR ADV 85.02 78 999999999 85.02 103.55 percent of total billed charges THYROXINE; FREE 3018443901_1 CDM 301 RC 84439 HCPCS outpatient 109 81.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 95.45 87.57 999999999 85.02 103.55 percent of total billed charges THYROXINE; FREE 3018443901_1 CDM 301 RC 84439 HCPCS outpatient 109 81.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 92.73 85.07 999999999 85.02 103.55 percent of total billed charges THYROXINE; FREE 3018443901_1 CDM 301 RC 84439 HCPCS outpatient 109 81.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 92.73 85.07 999999999 85.02 103.55 percent of total billed charges THYROXINE; FREE 3018443901_1 CDM 301 RC 84439 HCPCS outpatient 109 81.75 MOLINA MCAID MOLINA MCAID 90.91 83.4 999999999 85.02 103.55 percent of total billed charges THYROXINE; FREE 3018443901_1 CDM 301 RC 84439 HCPCS outpatient 109 81.75 MOLINA MCR ADV MOLINA MCR ADV 97.01 89 999999999 85.02 103.55 percent of total billed charges THYROXINE; FREE 3018443901_1 CDM 301 RC 84439 HCPCS outpatient 109 81.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 97.01 89 999999999 85.02 103.55 percent of total billed charges THYROXINE; FREE 3018443901_1 CDM 301 RC 84439 HCPCS outpatient 109 81.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 97.01 89 999999999 85.02 103.55 percent of total billed charges THYROXINE; FREE 3018443901_1 CDM 301 RC 84439 HCPCS outpatient 109 81.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 98.1 90 999999999 85.02 103.55 percent of total billed charges THYROXINE; FREE 3018443901_1 CDM 301 RC 84439 HCPCS outpatient 109 81.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 103.55 95 999999999 85.02 103.55 percent of total billed charges THYROXINE; FREE 3018443901_1 CDM 301 RC 84439 HCPCS outpatient 109 81.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 103.55 95 999999999 85.02 103.55 percent of total billed charges THYROXINE; FREE 3018443901_1 CDM 301 RC 84439 HCPCS outpatient 109 81.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 97.01 89 999999999 85.02 103.55 percent of total billed charges THYROXINE; FREE 3018443901_1 CDM 301 RC 84439 HCPCS outpatient 109 81.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 95.92 88 999999999 85.02 103.55 percent of total billed charges THYROXINE; FREE 3018443901_1 CDM 301 RC 84439 HCPCS outpatient 109 81.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 97.01 89 999999999 85.02 103.55 percent of total billed charges THYROID STIMULATING HORMONE (TSH) 3018444301_1 CDM 301 RC 84443 HCPCS outpatient 125 93.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 112.5 90 999999999 97.5 118.75 percent of total billed charges THYROID STIMULATING HORMONE (TSH) 3018444301_1 CDM 301 RC 84443 HCPCS outpatient 125 93.75 AETNA MCR ADV AETNA MCR ADV 97.5 78 999999999 97.5 118.75 percent of total billed charges THYROID STIMULATING HORMONE (TSH) 3018444301_1 CDM 301 RC 84443 HCPCS outpatient 125 93.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 109.46 87.57 999999999 97.5 118.75 percent of total billed charges THYROID STIMULATING HORMONE (TSH) 3018444301_1 CDM 301 RC 84443 HCPCS outpatient 125 93.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 106.34 85.07 999999999 97.5 118.75 percent of total billed charges THYROID STIMULATING HORMONE (TSH) 3018444301_1 CDM 301 RC 84443 HCPCS outpatient 125 93.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 106.34 85.07 999999999 97.5 118.75 percent of total billed charges THYROID STIMULATING HORMONE (TSH) 3018444301_1 CDM 301 RC 84443 HCPCS outpatient 125 93.75 MOLINA MCAID MOLINA MCAID 104.25 83.4 999999999 97.5 118.75 percent of total billed charges THYROID STIMULATING HORMONE (TSH) 3018444301_1 CDM 301 RC 84443 HCPCS outpatient 125 93.75 MOLINA MCR ADV MOLINA MCR ADV 111.25 89 999999999 97.5 118.75 percent of total billed charges THYROID STIMULATING HORMONE (TSH) 3018444301_1 CDM 301 RC 84443 HCPCS outpatient 125 93.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 111.25 89 999999999 97.5 118.75 percent of total billed charges THYROID STIMULATING HORMONE (TSH) 3018444301_1 CDM 301 RC 84443 HCPCS outpatient 125 93.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 111.25 89 999999999 97.5 118.75 percent of total billed charges THYROID STIMULATING HORMONE (TSH) 3018444301_1 CDM 301 RC 84443 HCPCS outpatient 125 93.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 112.5 90 999999999 97.5 118.75 percent of total billed charges THYROID STIMULATING HORMONE (TSH) 3018444301_1 CDM 301 RC 84443 HCPCS outpatient 125 93.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 118.75 95 999999999 97.5 118.75 percent of total billed charges THYROID STIMULATING HORMONE (TSH) 3018444301_1 CDM 301 RC 84443 HCPCS outpatient 125 93.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 118.75 95 999999999 97.5 118.75 percent of total billed charges THYROID STIMULATING HORMONE (TSH) 3018444301_1 CDM 301 RC 84443 HCPCS outpatient 125 93.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 111.25 89 999999999 97.5 118.75 percent of total billed charges THYROID STIMULATING HORMONE (TSH) 3018444301_1 CDM 301 RC 84443 HCPCS outpatient 125 93.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 110 88 999999999 97.5 118.75 percent of total billed charges THYROID STIMULATING HORMONE (TSH) 3018444301_1 CDM 301 RC 84443 HCPCS outpatient 125 93.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 111.25 89 999999999 97.5 118.75 percent of total billed charges TOCOPHEROL ALPHA (VITAMIN E) 3018444601_1 CDM 301 RC 84446 HCPCS outpatient 127 95.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 114.3 90 999999999 99.06 120.65 percent of total billed charges TOCOPHEROL ALPHA (VITAMIN E) 3018444601_1 CDM 301 RC 84446 HCPCS outpatient 127 95.25 AETNA MCR ADV AETNA MCR ADV 99.06 78 999999999 99.06 120.65 percent of total billed charges TOCOPHEROL ALPHA (VITAMIN E) 3018444601_1 CDM 301 RC 84446 HCPCS outpatient 127 95.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 111.21 87.57 999999999 99.06 120.65 percent of total billed charges TOCOPHEROL ALPHA (VITAMIN E) 3018444601_1 CDM 301 RC 84446 HCPCS outpatient 127 95.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 108.04 85.07 999999999 99.06 120.65 percent of total billed charges TOCOPHEROL ALPHA (VITAMIN E) 3018444601_1 CDM 301 RC 84446 HCPCS outpatient 127 95.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 108.04 85.07 999999999 99.06 120.65 percent of total billed charges TOCOPHEROL ALPHA (VITAMIN E) 3018444601_1 CDM 301 RC 84446 HCPCS outpatient 127 95.25 MOLINA MCAID MOLINA MCAID 105.92 83.4 999999999 99.06 120.65 percent of total billed charges TOCOPHEROL ALPHA (VITAMIN E) 3018444601_1 CDM 301 RC 84446 HCPCS outpatient 127 95.25 MOLINA MCR ADV MOLINA MCR ADV 113.03 89 999999999 99.06 120.65 percent of total billed charges TOCOPHEROL ALPHA (VITAMIN E) 3018444601_1 CDM 301 RC 84446 HCPCS outpatient 127 95.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 113.03 89 999999999 99.06 120.65 percent of total billed charges TOCOPHEROL ALPHA (VITAMIN E) 3018444601_1 CDM 301 RC 84446 HCPCS outpatient 127 95.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 113.03 89 999999999 99.06 120.65 percent of total billed charges TOCOPHEROL ALPHA (VITAMIN E) 3018444601_1 CDM 301 RC 84446 HCPCS outpatient 127 95.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 114.3 90 999999999 99.06 120.65 percent of total billed charges TOCOPHEROL ALPHA (VITAMIN E) 3018444601_1 CDM 301 RC 84446 HCPCS outpatient 127 95.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 120.65 95 999999999 99.06 120.65 percent of total billed charges TOCOPHEROL ALPHA (VITAMIN E) 3018444601_1 CDM 301 RC 84446 HCPCS outpatient 127 95.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 120.65 95 999999999 99.06 120.65 percent of total billed charges TOCOPHEROL ALPHA (VITAMIN E) 3018444601_1 CDM 301 RC 84446 HCPCS outpatient 127 95.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 113.03 89 999999999 99.06 120.65 percent of total billed charges TOCOPHEROL ALPHA (VITAMIN E) 3018444601_1 CDM 301 RC 84446 HCPCS outpatient 127 95.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 111.76 88 999999999 99.06 120.65 percent of total billed charges TOCOPHEROL ALPHA (VITAMIN E) 3018444601_1 CDM 301 RC 84446 HCPCS outpatient 127 95.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 113.03 89 999999999 99.06 120.65 percent of total billed charges TRANSFERASE; ASPARTATE AMINO (AST) (SGOT) 3018445001_1 CDM 301 RC 84450 HCPCS outpatient 61 45.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 54.9 90 999999999 47.58 57.95 percent of total billed charges TRANSFERASE; ASPARTATE AMINO (AST) (SGOT) 3018445001_1 CDM 301 RC 84450 HCPCS outpatient 61 45.75 AETNA MCR ADV AETNA MCR ADV 47.58 78 999999999 47.58 57.95 percent of total billed charges TRANSFERASE; ASPARTATE AMINO (AST) (SGOT) 3018445001_1 CDM 301 RC 84450 HCPCS outpatient 61 45.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 53.42 87.57 999999999 47.58 57.95 percent of total billed charges TRANSFERASE; ASPARTATE AMINO (AST) (SGOT) 3018445001_1 CDM 301 RC 84450 HCPCS outpatient 61 45.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 51.89 85.07 999999999 47.58 57.95 percent of total billed charges TRANSFERASE; ASPARTATE AMINO (AST) (SGOT) 3018445001_1 CDM 301 RC 84450 HCPCS outpatient 61 45.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 51.89 85.07 999999999 47.58 57.95 percent of total billed charges TRANSFERASE; ASPARTATE AMINO (AST) (SGOT) 3018445001_1 CDM 301 RC 84450 HCPCS outpatient 61 45.75 MOLINA MCAID MOLINA MCAID 50.87 83.4 999999999 47.58 57.95 percent of total billed charges TRANSFERASE; ASPARTATE AMINO (AST) (SGOT) 3018445001_1 CDM 301 RC 84450 HCPCS outpatient 61 45.75 MOLINA MCR ADV MOLINA MCR ADV 54.29 89 999999999 47.58 57.95 percent of total billed charges TRANSFERASE; ASPARTATE AMINO (AST) (SGOT) 3018445001_1 CDM 301 RC 84450 HCPCS outpatient 61 45.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 54.29 89 999999999 47.58 57.95 percent of total billed charges TRANSFERASE; ASPARTATE AMINO (AST) (SGOT) 3018445001_1 CDM 301 RC 84450 HCPCS outpatient 61 45.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 54.29 89 999999999 47.58 57.95 percent of total billed charges TRANSFERASE; ASPARTATE AMINO (AST) (SGOT) 3018445001_1 CDM 301 RC 84450 HCPCS outpatient 61 45.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 54.9 90 999999999 47.58 57.95 percent of total billed charges TRANSFERASE; ASPARTATE AMINO (AST) (SGOT) 3018445001_1 CDM 301 RC 84450 HCPCS outpatient 61 45.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 57.95 95 999999999 47.58 57.95 percent of total billed charges TRANSFERASE; ASPARTATE AMINO (AST) (SGOT) 3018445001_1 CDM 301 RC 84450 HCPCS outpatient 61 45.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 57.95 95 999999999 47.58 57.95 percent of total billed charges TRANSFERASE; ASPARTATE AMINO (AST) (SGOT) 3018445001_1 CDM 301 RC 84450 HCPCS outpatient 61 45.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 54.29 89 999999999 47.58 57.95 percent of total billed charges TRANSFERASE; ASPARTATE AMINO (AST) (SGOT) 3018445001_1 CDM 301 RC 84450 HCPCS outpatient 61 45.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 53.68 88 999999999 47.58 57.95 percent of total billed charges TRANSFERASE; ASPARTATE AMINO (AST) (SGOT) 3018445001_1 CDM 301 RC 84450 HCPCS outpatient 61 45.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 54.29 89 999999999 47.58 57.95 percent of total billed charges TRANSFERASE; ALANINE AMINO (ALT) (SGPT) 3018446001_1 CDM 301 RC 84460 HCPCS outpatient 63 47.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 56.7 90 999999999 49.14 59.85 percent of total billed charges TRANSFERASE; ALANINE AMINO (ALT) (SGPT) 3018446001_1 CDM 301 RC 84460 HCPCS outpatient 63 47.25 AETNA MCR ADV AETNA MCR ADV 49.14 78 999999999 49.14 59.85 percent of total billed charges TRANSFERASE; ALANINE AMINO (ALT) (SGPT) 3018446001_1 CDM 301 RC 84460 HCPCS outpatient 63 47.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 55.17 87.57 999999999 49.14 59.85 percent of total billed charges TRANSFERASE; ALANINE AMINO (ALT) (SGPT) 3018446001_1 CDM 301 RC 84460 HCPCS outpatient 63 47.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 53.59 85.07 999999999 49.14 59.85 percent of total billed charges TRANSFERASE; ALANINE AMINO (ALT) (SGPT) 3018446001_1 CDM 301 RC 84460 HCPCS outpatient 63 47.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 53.59 85.07 999999999 49.14 59.85 percent of total billed charges TRANSFERASE; ALANINE AMINO (ALT) (SGPT) 3018446001_1 CDM 301 RC 84460 HCPCS outpatient 63 47.25 MOLINA MCAID MOLINA MCAID 52.54 83.4 999999999 49.14 59.85 percent of total billed charges TRANSFERASE; ALANINE AMINO (ALT) (SGPT) 3018446001_1 CDM 301 RC 84460 HCPCS outpatient 63 47.25 MOLINA MCR ADV MOLINA MCR ADV 56.07 89 999999999 49.14 59.85 percent of total billed charges TRANSFERASE; ALANINE AMINO (ALT) (SGPT) 3018446001_1 CDM 301 RC 84460 HCPCS outpatient 63 47.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 56.07 89 999999999 49.14 59.85 percent of total billed charges TRANSFERASE; ALANINE AMINO (ALT) (SGPT) 3018446001_1 CDM 301 RC 84460 HCPCS outpatient 63 47.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 56.07 89 999999999 49.14 59.85 percent of total billed charges TRANSFERASE; ALANINE AMINO (ALT) (SGPT) 3018446001_1 CDM 301 RC 84460 HCPCS outpatient 63 47.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 56.7 90 999999999 49.14 59.85 percent of total billed charges TRANSFERASE; ALANINE AMINO (ALT) (SGPT) 3018446001_1 CDM 301 RC 84460 HCPCS outpatient 63 47.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 59.85 95 999999999 49.14 59.85 percent of total billed charges TRANSFERASE; ALANINE AMINO (ALT) (SGPT) 3018446001_1 CDM 301 RC 84460 HCPCS outpatient 63 47.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 59.85 95 999999999 49.14 59.85 percent of total billed charges TRANSFERASE; ALANINE AMINO (ALT) (SGPT) 3018446001_1 CDM 301 RC 84460 HCPCS outpatient 63 47.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 56.07 89 999999999 49.14 59.85 percent of total billed charges TRANSFERASE; ALANINE AMINO (ALT) (SGPT) 3018446001_1 CDM 301 RC 84460 HCPCS outpatient 63 47.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 55.44 88 999999999 49.14 59.85 percent of total billed charges TRANSFERASE; ALANINE AMINO (ALT) (SGPT) 3018446001_1 CDM 301 RC 84460 HCPCS outpatient 63 47.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 56.07 89 999999999 49.14 59.85 percent of total billed charges TRANSFERRIN 3018446601_1 CDM 301 RC 84466 HCPCS outpatient 126 94.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 113.4 90 999999999 98.28 119.7 percent of total billed charges TRANSFERRIN 3018446601_1 CDM 301 RC 84466 HCPCS outpatient 126 94.5 AETNA MCR ADV AETNA MCR ADV 98.28 78 999999999 98.28 119.7 percent of total billed charges TRANSFERRIN 3018446601_1 CDM 301 RC 84466 HCPCS outpatient 126 94.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 110.34 87.57 999999999 98.28 119.7 percent of total billed charges TRANSFERRIN 3018446601_1 CDM 301 RC 84466 HCPCS outpatient 126 94.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 107.19 85.07 999999999 98.28 119.7 percent of total billed charges TRANSFERRIN 3018446601_1 CDM 301 RC 84466 HCPCS outpatient 126 94.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 107.19 85.07 999999999 98.28 119.7 percent of total billed charges TRANSFERRIN 3018446601_1 CDM 301 RC 84466 HCPCS outpatient 126 94.5 MOLINA MCAID MOLINA MCAID 105.08 83.4 999999999 98.28 119.7 percent of total billed charges TRANSFERRIN 3018446601_1 CDM 301 RC 84466 HCPCS outpatient 126 94.5 MOLINA MCR ADV MOLINA MCR ADV 112.14 89 999999999 98.28 119.7 percent of total billed charges TRANSFERRIN 3018446601_1 CDM 301 RC 84466 HCPCS outpatient 126 94.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 112.14 89 999999999 98.28 119.7 percent of total billed charges TRANSFERRIN 3018446601_1 CDM 301 RC 84466 HCPCS outpatient 126 94.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 112.14 89 999999999 98.28 119.7 percent of total billed charges TRANSFERRIN 3018446601_1 CDM 301 RC 84466 HCPCS outpatient 126 94.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 113.4 90 999999999 98.28 119.7 percent of total billed charges TRANSFERRIN 3018446601_1 CDM 301 RC 84466 HCPCS outpatient 126 94.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 119.7 95 999999999 98.28 119.7 percent of total billed charges TRANSFERRIN 3018446601_1 CDM 301 RC 84466 HCPCS outpatient 126 94.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 119.7 95 999999999 98.28 119.7 percent of total billed charges TRANSFERRIN 3018446601_1 CDM 301 RC 84466 HCPCS outpatient 126 94.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 112.14 89 999999999 98.28 119.7 percent of total billed charges TRANSFERRIN 3018446601_1 CDM 301 RC 84466 HCPCS outpatient 126 94.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 110.88 88 999999999 98.28 119.7 percent of total billed charges TRANSFERRIN 3018446601_1 CDM 301 RC 84466 HCPCS outpatient 126 94.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 112.14 89 999999999 98.28 119.7 percent of total billed charges TRIGLYCERIDES 3018447801_1 CDM 301 RC 84478 HCPCS outpatient 46 34.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 41.4 90 999999999 35.88 43.7 percent of total billed charges TRIGLYCERIDES 3018447801_1 CDM 301 RC 84478 HCPCS outpatient 46 34.5 AETNA MCR ADV AETNA MCR ADV 35.88 78 999999999 35.88 43.7 percent of total billed charges TRIGLYCERIDES 3018447801_1 CDM 301 RC 84478 HCPCS outpatient 46 34.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 40.28 87.57 999999999 35.88 43.7 percent of total billed charges TRIGLYCERIDES 3018447801_1 CDM 301 RC 84478 HCPCS outpatient 46 34.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 39.13 85.07 999999999 35.88 43.7 percent of total billed charges TRIGLYCERIDES 3018447801_1 CDM 301 RC 84478 HCPCS outpatient 46 34.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 39.13 85.07 999999999 35.88 43.7 percent of total billed charges TRIGLYCERIDES 3018447801_1 CDM 301 RC 84478 HCPCS outpatient 46 34.5 MOLINA MCAID MOLINA MCAID 38.36 83.4 999999999 35.88 43.7 percent of total billed charges TRIGLYCERIDES 3018447801_1 CDM 301 RC 84478 HCPCS outpatient 46 34.5 MOLINA MCR ADV MOLINA MCR ADV 40.94 89 999999999 35.88 43.7 percent of total billed charges TRIGLYCERIDES 3018447801_1 CDM 301 RC 84478 HCPCS outpatient 46 34.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 40.94 89 999999999 35.88 43.7 percent of total billed charges TRIGLYCERIDES 3018447801_1 CDM 301 RC 84478 HCPCS outpatient 46 34.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 40.94 89 999999999 35.88 43.7 percent of total billed charges TRIGLYCERIDES 3018447801_1 CDM 301 RC 84478 HCPCS outpatient 46 34.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 41.4 90 999999999 35.88 43.7 percent of total billed charges TRIGLYCERIDES 3018447801_1 CDM 301 RC 84478 HCPCS outpatient 46 34.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 43.7 95 999999999 35.88 43.7 percent of total billed charges TRIGLYCERIDES 3018447801_1 CDM 301 RC 84478 HCPCS outpatient 46 34.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 43.7 95 999999999 35.88 43.7 percent of total billed charges TRIGLYCERIDES 3018447801_1 CDM 301 RC 84478 HCPCS outpatient 46 34.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 40.94 89 999999999 35.88 43.7 percent of total billed charges TRIGLYCERIDES 3018447801_1 CDM 301 RC 84478 HCPCS outpatient 46 34.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 40.48 88 999999999 35.88 43.7 percent of total billed charges TRIGLYCERIDES 3018447801_1 CDM 301 RC 84478 HCPCS outpatient 46 34.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 40.94 89 999999999 35.88 43.7 percent of total billed charges THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID HORMONE BINDING RATIO (THBR) 3018447901_1 CDM 301 RC 84479 HCPCS outpatient 63 47.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 56.7 90 999999999 49.14 59.85 percent of total billed charges THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID HORMONE BINDING RATIO (THBR) 3018447901_1 CDM 301 RC 84479 HCPCS outpatient 63 47.25 AETNA MCR ADV AETNA MCR ADV 49.14 78 999999999 49.14 59.85 percent of total billed charges THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID HORMONE BINDING RATIO (THBR) 3018447901_1 CDM 301 RC 84479 HCPCS outpatient 63 47.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 55.17 87.57 999999999 49.14 59.85 percent of total billed charges THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID HORMONE BINDING RATIO (THBR) 3018447901_1 CDM 301 RC 84479 HCPCS outpatient 63 47.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 53.59 85.07 999999999 49.14 59.85 percent of total billed charges THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID HORMONE BINDING RATIO (THBR) 3018447901_1 CDM 301 RC 84479 HCPCS outpatient 63 47.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 53.59 85.07 999999999 49.14 59.85 percent of total billed charges THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID HORMONE BINDING RATIO (THBR) 3018447901_1 CDM 301 RC 84479 HCPCS outpatient 63 47.25 MOLINA MCAID MOLINA MCAID 52.54 83.4 999999999 49.14 59.85 percent of total billed charges THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID HORMONE BINDING RATIO (THBR) 3018447901_1 CDM 301 RC 84479 HCPCS outpatient 63 47.25 MOLINA MCR ADV MOLINA MCR ADV 56.07 89 999999999 49.14 59.85 percent of total billed charges THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID HORMONE BINDING RATIO (THBR) 3018447901_1 CDM 301 RC 84479 HCPCS outpatient 63 47.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 56.07 89 999999999 49.14 59.85 percent of total billed charges THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID HORMONE BINDING RATIO (THBR) 3018447901_1 CDM 301 RC 84479 HCPCS outpatient 63 47.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 56.07 89 999999999 49.14 59.85 percent of total billed charges THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID HORMONE BINDING RATIO (THBR) 3018447901_1 CDM 301 RC 84479 HCPCS outpatient 63 47.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 56.7 90 999999999 49.14 59.85 percent of total billed charges THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID HORMONE BINDING RATIO (THBR) 3018447901_1 CDM 301 RC 84479 HCPCS outpatient 63 47.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 59.85 95 999999999 49.14 59.85 percent of total billed charges THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID HORMONE BINDING RATIO (THBR) 3018447901_1 CDM 301 RC 84479 HCPCS outpatient 63 47.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 59.85 95 999999999 49.14 59.85 percent of total billed charges THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID HORMONE BINDING RATIO (THBR) 3018447901_1 CDM 301 RC 84479 HCPCS outpatient 63 47.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 56.07 89 999999999 49.14 59.85 percent of total billed charges THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID HORMONE BINDING RATIO (THBR) 3018447901_1 CDM 301 RC 84479 HCPCS outpatient 63 47.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 55.44 88 999999999 49.14 59.85 percent of total billed charges THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID HORMONE BINDING RATIO (THBR) 3018447901_1 CDM 301 RC 84479 HCPCS outpatient 63 47.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 56.07 89 999999999 49.14 59.85 percent of total billed charges TRIIODOTHYRONINE T3; TOTAL (TT-3) 3018448001_1 CDM 301 RC 84480 HCPCS outpatient 86 64.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 77.4 90 999999999 67.08 81.7 percent of total billed charges TRIIODOTHYRONINE T3; TOTAL (TT-3) 3018448001_1 CDM 301 RC 84480 HCPCS outpatient 86 64.5 AETNA MCR ADV AETNA MCR ADV 67.08 78 999999999 67.08 81.7 percent of total billed charges TRIIODOTHYRONINE T3; TOTAL (TT-3) 3018448001_1 CDM 301 RC 84480 HCPCS outpatient 86 64.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 75.31 87.57 999999999 67.08 81.7 percent of total billed charges TRIIODOTHYRONINE T3; TOTAL (TT-3) 3018448001_1 CDM 301 RC 84480 HCPCS outpatient 86 64.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 73.16 85.07 999999999 67.08 81.7 percent of total billed charges TRIIODOTHYRONINE T3; TOTAL (TT-3) 3018448001_1 CDM 301 RC 84480 HCPCS outpatient 86 64.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 73.16 85.07 999999999 67.08 81.7 percent of total billed charges TRIIODOTHYRONINE T3; TOTAL (TT-3) 3018448001_1 CDM 301 RC 84480 HCPCS outpatient 86 64.5 MOLINA MCAID MOLINA MCAID 71.72 83.4 999999999 67.08 81.7 percent of total billed charges TRIIODOTHYRONINE T3; TOTAL (TT-3) 3018448001_1 CDM 301 RC 84480 HCPCS outpatient 86 64.5 MOLINA MCR ADV MOLINA MCR ADV 76.54 89 999999999 67.08 81.7 percent of total billed charges TRIIODOTHYRONINE T3; TOTAL (TT-3) 3018448001_1 CDM 301 RC 84480 HCPCS outpatient 86 64.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 76.54 89 999999999 67.08 81.7 percent of total billed charges TRIIODOTHYRONINE T3; TOTAL (TT-3) 3018448001_1 CDM 301 RC 84480 HCPCS outpatient 86 64.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 76.54 89 999999999 67.08 81.7 percent of total billed charges TRIIODOTHYRONINE T3; TOTAL (TT-3) 3018448001_1 CDM 301 RC 84480 HCPCS outpatient 86 64.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 77.4 90 999999999 67.08 81.7 percent of total billed charges TRIIODOTHYRONINE T3; TOTAL (TT-3) 3018448001_1 CDM 301 RC 84480 HCPCS outpatient 86 64.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 81.7 95 999999999 67.08 81.7 percent of total billed charges TRIIODOTHYRONINE T3; TOTAL (TT-3) 3018448001_1 CDM 301 RC 84480 HCPCS outpatient 86 64.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 81.7 95 999999999 67.08 81.7 percent of total billed charges TRIIODOTHYRONINE T3; TOTAL (TT-3) 3018448001_1 CDM 301 RC 84480 HCPCS outpatient 86 64.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 76.54 89 999999999 67.08 81.7 percent of total billed charges TRIIODOTHYRONINE T3; TOTAL (TT-3) 3018448001_1 CDM 301 RC 84480 HCPCS outpatient 86 64.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 75.68 88 999999999 67.08 81.7 percent of total billed charges TRIIODOTHYRONINE T3; TOTAL (TT-3) 3018448001_1 CDM 301 RC 84480 HCPCS outpatient 86 64.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 76.54 89 999999999 67.08 81.7 percent of total billed charges TRIIODOTHYRONINE T3; FREE 3018448101_1 CDM 301 RC 84481 HCPCS outpatient 137 102.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 123.3 90 999999999 106.86 130.15 percent of total billed charges TRIIODOTHYRONINE T3; FREE 3018448101_1 CDM 301 RC 84481 HCPCS outpatient 137 102.75 AETNA MCR ADV AETNA MCR ADV 106.86 78 999999999 106.86 130.15 percent of total billed charges TRIIODOTHYRONINE T3; FREE 3018448101_1 CDM 301 RC 84481 HCPCS outpatient 137 102.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 119.97 87.57 999999999 106.86 130.15 percent of total billed charges TRIIODOTHYRONINE T3; FREE 3018448101_1 CDM 301 RC 84481 HCPCS outpatient 137 102.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 116.55 85.07 999999999 106.86 130.15 percent of total billed charges TRIIODOTHYRONINE T3; FREE 3018448101_1 CDM 301 RC 84481 HCPCS outpatient 137 102.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 116.55 85.07 999999999 106.86 130.15 percent of total billed charges TRIIODOTHYRONINE T3; FREE 3018448101_1 CDM 301 RC 84481 HCPCS outpatient 137 102.75 MOLINA MCAID MOLINA MCAID 114.26 83.4 999999999 106.86 130.15 percent of total billed charges TRIIODOTHYRONINE T3; FREE 3018448101_1 CDM 301 RC 84481 HCPCS outpatient 137 102.75 MOLINA MCR ADV MOLINA MCR ADV 121.93 89 999999999 106.86 130.15 percent of total billed charges TRIIODOTHYRONINE T3; FREE 3018448101_1 CDM 301 RC 84481 HCPCS outpatient 137 102.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 121.93 89 999999999 106.86 130.15 percent of total billed charges TRIIODOTHYRONINE T3; FREE 3018448101_1 CDM 301 RC 84481 HCPCS outpatient 137 102.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 121.93 89 999999999 106.86 130.15 percent of total billed charges TRIIODOTHYRONINE T3; FREE 3018448101_1 CDM 301 RC 84481 HCPCS outpatient 137 102.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 123.3 90 999999999 106.86 130.15 percent of total billed charges TRIIODOTHYRONINE T3; FREE 3018448101_1 CDM 301 RC 84481 HCPCS outpatient 137 102.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 130.15 95 999999999 106.86 130.15 percent of total billed charges TRIIODOTHYRONINE T3; FREE 3018448101_1 CDM 301 RC 84481 HCPCS outpatient 137 102.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 130.15 95 999999999 106.86 130.15 percent of total billed charges TRIIODOTHYRONINE T3; FREE 3018448101_1 CDM 301 RC 84481 HCPCS outpatient 137 102.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 121.93 89 999999999 106.86 130.15 percent of total billed charges TRIIODOTHYRONINE T3; FREE 3018448101_1 CDM 301 RC 84481 HCPCS outpatient 137 102.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 120.56 88 999999999 106.86 130.15 percent of total billed charges TRIIODOTHYRONINE T3; FREE 3018448101_1 CDM 301 RC 84481 HCPCS outpatient 137 102.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 121.93 89 999999999 106.86 130.15 percent of total billed charges "TROPONIN, QUANTITATIVE" 3018448401_1 CDM 301 RC 84484 HCPCS outpatient 172 129 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 154.8 90 999999999 134.16 163.4 percent of total billed charges "TROPONIN, QUANTITATIVE" 3018448401_1 CDM 301 RC 84484 HCPCS outpatient 172 129 AETNA MCR ADV AETNA MCR ADV 134.16 78 999999999 134.16 163.4 percent of total billed charges "TROPONIN, QUANTITATIVE" 3018448401_1 CDM 301 RC 84484 HCPCS outpatient 172 129 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 150.62 87.57 999999999 134.16 163.4 percent of total billed charges "TROPONIN, QUANTITATIVE" 3018448401_1 CDM 301 RC 84484 HCPCS outpatient 172 129 COORDINATED CARE MCAID COORDINATED CARE MCAID 146.32 85.07 999999999 134.16 163.4 percent of total billed charges "TROPONIN, QUANTITATIVE" 3018448401_1 CDM 301 RC 84484 HCPCS outpatient 172 129 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 146.32 85.07 999999999 134.16 163.4 percent of total billed charges "TROPONIN, QUANTITATIVE" 3018448401_1 CDM 301 RC 84484 HCPCS outpatient 172 129 MOLINA MCAID MOLINA MCAID 143.45 83.4 999999999 134.16 163.4 percent of total billed charges "TROPONIN, QUANTITATIVE" 3018448401_1 CDM 301 RC 84484 HCPCS outpatient 172 129 MOLINA MCR ADV MOLINA MCR ADV 153.08 89 999999999 134.16 163.4 percent of total billed charges "TROPONIN, QUANTITATIVE" 3018448401_1 CDM 301 RC 84484 HCPCS outpatient 172 129 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 153.08 89 999999999 134.16 163.4 percent of total billed charges "TROPONIN, QUANTITATIVE" 3018448401_1 CDM 301 RC 84484 HCPCS outpatient 172 129 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 153.08 89 999999999 134.16 163.4 percent of total billed charges "TROPONIN, QUANTITATIVE" 3018448401_1 CDM 301 RC 84484 HCPCS outpatient 172 129 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 154.8 90 999999999 134.16 163.4 percent of total billed charges "TROPONIN, QUANTITATIVE" 3018448401_1 CDM 301 RC 84484 HCPCS outpatient 172 129 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 163.4 95 999999999 134.16 163.4 percent of total billed charges "TROPONIN, QUANTITATIVE" 3018448401_1 CDM 301 RC 84484 HCPCS outpatient 172 129 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 163.4 95 999999999 134.16 163.4 percent of total billed charges "TROPONIN, QUANTITATIVE" 3018448401_1 CDM 301 RC 84484 HCPCS outpatient 172 129 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 153.08 89 999999999 134.16 163.4 percent of total billed charges "TROPONIN, QUANTITATIVE" 3018448401_1 CDM 301 RC 84484 HCPCS outpatient 172 129 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 151.36 88 999999999 134.16 163.4 percent of total billed charges "TROPONIN, QUANTITATIVE" 3018448401_1 CDM 301 RC 84484 HCPCS outpatient 172 129 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 153.08 89 999999999 134.16 163.4 percent of total billed charges UREA NITROGEN; QUANTITATIVE 3018452001_1 CDM 301 RC 84520 HCPCS outpatient 56 42 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50.4 90 999999999 43.68 53.2 percent of total billed charges UREA NITROGEN; QUANTITATIVE 3018452001_1 CDM 301 RC 84520 HCPCS outpatient 56 42 AETNA MCR ADV AETNA MCR ADV 43.68 78 999999999 43.68 53.2 percent of total billed charges UREA NITROGEN; QUANTITATIVE 3018452001_1 CDM 301 RC 84520 HCPCS outpatient 56 42 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 49.04 87.57 999999999 43.68 53.2 percent of total billed charges UREA NITROGEN; QUANTITATIVE 3018452001_1 CDM 301 RC 84520 HCPCS outpatient 56 42 COORDINATED CARE MCAID COORDINATED CARE MCAID 47.64 85.07 999999999 43.68 53.2 percent of total billed charges UREA NITROGEN; QUANTITATIVE 3018452001_1 CDM 301 RC 84520 HCPCS outpatient 56 42 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 47.64 85.07 999999999 43.68 53.2 percent of total billed charges UREA NITROGEN; QUANTITATIVE 3018452001_1 CDM 301 RC 84520 HCPCS outpatient 56 42 MOLINA MCAID MOLINA MCAID 46.7 83.4 999999999 43.68 53.2 percent of total billed charges UREA NITROGEN; QUANTITATIVE 3018452001_1 CDM 301 RC 84520 HCPCS outpatient 56 42 MOLINA MCR ADV MOLINA MCR ADV 49.84 89 999999999 43.68 53.2 percent of total billed charges UREA NITROGEN; QUANTITATIVE 3018452001_1 CDM 301 RC 84520 HCPCS outpatient 56 42 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 49.84 89 999999999 43.68 53.2 percent of total billed charges UREA NITROGEN; QUANTITATIVE 3018452001_1 CDM 301 RC 84520 HCPCS outpatient 56 42 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 49.84 89 999999999 43.68 53.2 percent of total billed charges UREA NITROGEN; QUANTITATIVE 3018452001_1 CDM 301 RC 84520 HCPCS outpatient 56 42 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50.4 90 999999999 43.68 53.2 percent of total billed charges UREA NITROGEN; QUANTITATIVE 3018452001_1 CDM 301 RC 84520 HCPCS outpatient 56 42 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 53.2 95 999999999 43.68 53.2 percent of total billed charges UREA NITROGEN; QUANTITATIVE 3018452001_1 CDM 301 RC 84520 HCPCS outpatient 56 42 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 53.2 95 999999999 43.68 53.2 percent of total billed charges UREA NITROGEN; QUANTITATIVE 3018452001_1 CDM 301 RC 84520 HCPCS outpatient 56 42 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 49.84 89 999999999 43.68 53.2 percent of total billed charges UREA NITROGEN; QUANTITATIVE 3018452001_1 CDM 301 RC 84520 HCPCS outpatient 56 42 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 49.28 88 999999999 43.68 53.2 percent of total billed charges UREA NITROGEN; QUANTITATIVE 3018452001_1 CDM 301 RC 84520 HCPCS outpatient 56 42 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 49.84 89 999999999 43.68 53.2 percent of total billed charges URIC ACID; BLOOD 3018455001_1 CDM 301 RC 84550 HCPCS outpatient 67 50.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 60.3 90 999999999 52.26 63.65 percent of total billed charges URIC ACID; BLOOD 3018455001_1 CDM 301 RC 84550 HCPCS outpatient 67 50.25 AETNA MCR ADV AETNA MCR ADV 52.26 78 999999999 52.26 63.65 percent of total billed charges URIC ACID; BLOOD 3018455001_1 CDM 301 RC 84550 HCPCS outpatient 67 50.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 58.67 87.57 999999999 52.26 63.65 percent of total billed charges URIC ACID; BLOOD 3018455001_1 CDM 301 RC 84550 HCPCS outpatient 67 50.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 57 85.07 999999999 52.26 63.65 percent of total billed charges URIC ACID; BLOOD 3018455001_1 CDM 301 RC 84550 HCPCS outpatient 67 50.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 57 85.07 999999999 52.26 63.65 percent of total billed charges URIC ACID; BLOOD 3018455001_1 CDM 301 RC 84550 HCPCS outpatient 67 50.25 MOLINA MCAID MOLINA MCAID 55.88 83.4 999999999 52.26 63.65 percent of total billed charges URIC ACID; BLOOD 3018455001_1 CDM 301 RC 84550 HCPCS outpatient 67 50.25 MOLINA MCR ADV MOLINA MCR ADV 59.63 89 999999999 52.26 63.65 percent of total billed charges URIC ACID; BLOOD 3018455001_1 CDM 301 RC 84550 HCPCS outpatient 67 50.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 59.63 89 999999999 52.26 63.65 percent of total billed charges URIC ACID; BLOOD 3018455001_1 CDM 301 RC 84550 HCPCS outpatient 67 50.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 59.63 89 999999999 52.26 63.65 percent of total billed charges URIC ACID; BLOOD 3018455001_1 CDM 301 RC 84550 HCPCS outpatient 67 50.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 60.3 90 999999999 52.26 63.65 percent of total billed charges URIC ACID; BLOOD 3018455001_1 CDM 301 RC 84550 HCPCS outpatient 67 50.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 63.65 95 999999999 52.26 63.65 percent of total billed charges URIC ACID; BLOOD 3018455001_1 CDM 301 RC 84550 HCPCS outpatient 67 50.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 63.65 95 999999999 52.26 63.65 percent of total billed charges URIC ACID; BLOOD 3018455001_1 CDM 301 RC 84550 HCPCS outpatient 67 50.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 59.63 89 999999999 52.26 63.65 percent of total billed charges URIC ACID; BLOOD 3018455001_1 CDM 301 RC 84550 HCPCS outpatient 67 50.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 58.96 88 999999999 52.26 63.65 percent of total billed charges URIC ACID; BLOOD 3018455001_1 CDM 301 RC 84550 HCPCS outpatient 67 50.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 59.63 89 999999999 52.26 63.65 percent of total billed charges URIC ACID; OTHER SOURCE 3018456001_1 CDM 301 RC 84560 HCPCS outpatient 54 40.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 48.6 90 999999999 42.12 51.3 percent of total billed charges URIC ACID; OTHER SOURCE 3018456001_1 CDM 301 RC 84560 HCPCS outpatient 54 40.5 AETNA MCR ADV AETNA MCR ADV 42.12 78 999999999 42.12 51.3 percent of total billed charges URIC ACID; OTHER SOURCE 3018456001_1 CDM 301 RC 84560 HCPCS outpatient 54 40.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 47.29 87.57 999999999 42.12 51.3 percent of total billed charges URIC ACID; OTHER SOURCE 3018456001_1 CDM 301 RC 84560 HCPCS outpatient 54 40.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 45.94 85.07 999999999 42.12 51.3 percent of total billed charges URIC ACID; OTHER SOURCE 3018456001_1 CDM 301 RC 84560 HCPCS outpatient 54 40.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 45.94 85.07 999999999 42.12 51.3 percent of total billed charges URIC ACID; OTHER SOURCE 3018456001_1 CDM 301 RC 84560 HCPCS outpatient 54 40.5 MOLINA MCAID MOLINA MCAID 45.04 83.4 999999999 42.12 51.3 percent of total billed charges URIC ACID; OTHER SOURCE 3018456001_1 CDM 301 RC 84560 HCPCS outpatient 54 40.5 MOLINA MCR ADV MOLINA MCR ADV 48.06 89 999999999 42.12 51.3 percent of total billed charges URIC ACID; OTHER SOURCE 3018456001_1 CDM 301 RC 84560 HCPCS outpatient 54 40.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 48.06 89 999999999 42.12 51.3 percent of total billed charges URIC ACID; OTHER SOURCE 3018456001_1 CDM 301 RC 84560 HCPCS outpatient 54 40.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 48.06 89 999999999 42.12 51.3 percent of total billed charges URIC ACID; OTHER SOURCE 3018456001_1 CDM 301 RC 84560 HCPCS outpatient 54 40.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 48.6 90 999999999 42.12 51.3 percent of total billed charges URIC ACID; OTHER SOURCE 3018456001_1 CDM 301 RC 84560 HCPCS outpatient 54 40.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 51.3 95 999999999 42.12 51.3 percent of total billed charges URIC ACID; OTHER SOURCE 3018456001_1 CDM 301 RC 84560 HCPCS outpatient 54 40.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 51.3 95 999999999 42.12 51.3 percent of total billed charges URIC ACID; OTHER SOURCE 3018456001_1 CDM 301 RC 84560 HCPCS outpatient 54 40.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 48.06 89 999999999 42.12 51.3 percent of total billed charges URIC ACID; OTHER SOURCE 3018456001_1 CDM 301 RC 84560 HCPCS outpatient 54 40.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 47.52 88 999999999 42.12 51.3 percent of total billed charges URIC ACID; OTHER SOURCE 3018456001_1 CDM 301 RC 84560 HCPCS outpatient 54 40.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 48.06 89 999999999 42.12 51.3 percent of total billed charges "VASOPRESSIN (ANTIDIURETIC HORMONE, ADH)" 3018458801_1 CDM 301 RC 84588 HCPCS outpatient 208 156 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 187.2 90 999999999 162.24 197.6 percent of total billed charges "VASOPRESSIN (ANTIDIURETIC HORMONE, ADH)" 3018458801_1 CDM 301 RC 84588 HCPCS outpatient 208 156 AETNA MCR ADV AETNA MCR ADV 162.24 78 999999999 162.24 197.6 percent of total billed charges "VASOPRESSIN (ANTIDIURETIC HORMONE, ADH)" 3018458801_1 CDM 301 RC 84588 HCPCS outpatient 208 156 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 182.15 87.57 999999999 162.24 197.6 percent of total billed charges "VASOPRESSIN (ANTIDIURETIC HORMONE, ADH)" 3018458801_1 CDM 301 RC 84588 HCPCS outpatient 208 156 COORDINATED CARE MCAID COORDINATED CARE MCAID 176.95 85.07 999999999 162.24 197.6 percent of total billed charges "VASOPRESSIN (ANTIDIURETIC HORMONE, ADH)" 3018458801_1 CDM 301 RC 84588 HCPCS outpatient 208 156 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 176.95 85.07 999999999 162.24 197.6 percent of total billed charges "VASOPRESSIN (ANTIDIURETIC HORMONE, ADH)" 3018458801_1 CDM 301 RC 84588 HCPCS outpatient 208 156 MOLINA MCAID MOLINA MCAID 173.47 83.4 999999999 162.24 197.6 percent of total billed charges "VASOPRESSIN (ANTIDIURETIC HORMONE, ADH)" 3018458801_1 CDM 301 RC 84588 HCPCS outpatient 208 156 MOLINA MCR ADV MOLINA MCR ADV 185.12 89 999999999 162.24 197.6 percent of total billed charges "VASOPRESSIN (ANTIDIURETIC HORMONE, ADH)" 3018458801_1 CDM 301 RC 84588 HCPCS outpatient 208 156 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 185.12 89 999999999 162.24 197.6 percent of total billed charges "VASOPRESSIN (ANTIDIURETIC HORMONE, ADH)" 3018458801_1 CDM 301 RC 84588 HCPCS outpatient 208 156 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 185.12 89 999999999 162.24 197.6 percent of total billed charges "VASOPRESSIN (ANTIDIURETIC HORMONE, ADH)" 3018458801_1 CDM 301 RC 84588 HCPCS outpatient 208 156 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 187.2 90 999999999 162.24 197.6 percent of total billed charges "VASOPRESSIN (ANTIDIURETIC HORMONE, ADH)" 3018458801_1 CDM 301 RC 84588 HCPCS outpatient 208 156 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 197.6 95 999999999 162.24 197.6 percent of total billed charges "VASOPRESSIN (ANTIDIURETIC HORMONE, ADH)" 3018458801_1 CDM 301 RC 84588 HCPCS outpatient 208 156 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 197.6 95 999999999 162.24 197.6 percent of total billed charges "VASOPRESSIN (ANTIDIURETIC HORMONE, ADH)" 3018458801_1 CDM 301 RC 84588 HCPCS outpatient 208 156 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 185.12 89 999999999 162.24 197.6 percent of total billed charges "VASOPRESSIN (ANTIDIURETIC HORMONE, ADH)" 3018458801_1 CDM 301 RC 84588 HCPCS outpatient 208 156 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 183.04 88 999999999 162.24 197.6 percent of total billed charges "VASOPRESSIN (ANTIDIURETIC HORMONE, ADH)" 3018458801_1 CDM 301 RC 84588 HCPCS outpatient 208 156 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 185.12 89 999999999 162.24 197.6 percent of total billed charges VITAMIN A 3018459001_1 CDM 301 RC 84590 HCPCS outpatient 149 111.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 134.1 90 999999999 116.22 141.55 percent of total billed charges VITAMIN A 3018459001_1 CDM 301 RC 84590 HCPCS outpatient 149 111.75 AETNA MCR ADV AETNA MCR ADV 116.22 78 999999999 116.22 141.55 percent of total billed charges VITAMIN A 3018459001_1 CDM 301 RC 84590 HCPCS outpatient 149 111.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 130.48 87.57 999999999 116.22 141.55 percent of total billed charges VITAMIN A 3018459001_1 CDM 301 RC 84590 HCPCS outpatient 149 111.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 126.75 85.07 999999999 116.22 141.55 percent of total billed charges VITAMIN A 3018459001_1 CDM 301 RC 84590 HCPCS outpatient 149 111.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 126.75 85.07 999999999 116.22 141.55 percent of total billed charges VITAMIN A 3018459001_1 CDM 301 RC 84590 HCPCS outpatient 149 111.75 MOLINA MCAID MOLINA MCAID 124.27 83.4 999999999 116.22 141.55 percent of total billed charges VITAMIN A 3018459001_1 CDM 301 RC 84590 HCPCS outpatient 149 111.75 MOLINA MCR ADV MOLINA MCR ADV 132.61 89 999999999 116.22 141.55 percent of total billed charges VITAMIN A 3018459001_1 CDM 301 RC 84590 HCPCS outpatient 149 111.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 132.61 89 999999999 116.22 141.55 percent of total billed charges VITAMIN A 3018459001_1 CDM 301 RC 84590 HCPCS outpatient 149 111.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 132.61 89 999999999 116.22 141.55 percent of total billed charges VITAMIN A 3018459001_1 CDM 301 RC 84590 HCPCS outpatient 149 111.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 134.1 90 999999999 116.22 141.55 percent of total billed charges VITAMIN A 3018459001_1 CDM 301 RC 84590 HCPCS outpatient 149 111.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 141.55 95 999999999 116.22 141.55 percent of total billed charges VITAMIN A 3018459001_1 CDM 301 RC 84590 HCPCS outpatient 149 111.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 141.55 95 999999999 116.22 141.55 percent of total billed charges VITAMIN A 3018459001_1 CDM 301 RC 84590 HCPCS outpatient 149 111.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 132.61 89 999999999 116.22 141.55 percent of total billed charges VITAMIN A 3018459001_1 CDM 301 RC 84590 HCPCS outpatient 149 111.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 131.12 88 999999999 116.22 141.55 percent of total billed charges VITAMIN A 3018459001_1 CDM 301 RC 84590 HCPCS outpatient 149 111.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 132.61 89 999999999 116.22 141.55 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUANTITATIVE" 3018470201_1 CDM 301 RC 84702 HCPCS outpatient 107 80.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 96.3 90 999999999 83.46 101.65 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUANTITATIVE" 3018470201_1 CDM 301 RC 84702 HCPCS outpatient 107 80.25 AETNA MCR ADV AETNA MCR ADV 83.46 78 999999999 83.46 101.65 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUANTITATIVE" 3018470201_1 CDM 301 RC 84702 HCPCS outpatient 107 80.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 93.7 87.57 999999999 83.46 101.65 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUANTITATIVE" 3018470201_1 CDM 301 RC 84702 HCPCS outpatient 107 80.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 91.02 85.07 999999999 83.46 101.65 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUANTITATIVE" 3018470201_1 CDM 301 RC 84702 HCPCS outpatient 107 80.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 91.02 85.07 999999999 83.46 101.65 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUANTITATIVE" 3018470201_1 CDM 301 RC 84702 HCPCS outpatient 107 80.25 MOLINA MCAID MOLINA MCAID 89.24 83.4 999999999 83.46 101.65 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUANTITATIVE" 3018470201_1 CDM 301 RC 84702 HCPCS outpatient 107 80.25 MOLINA MCR ADV MOLINA MCR ADV 95.23 89 999999999 83.46 101.65 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUANTITATIVE" 3018470201_1 CDM 301 RC 84702 HCPCS outpatient 107 80.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 95.23 89 999999999 83.46 101.65 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUANTITATIVE" 3018470201_1 CDM 301 RC 84702 HCPCS outpatient 107 80.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 95.23 89 999999999 83.46 101.65 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUANTITATIVE" 3018470201_1 CDM 301 RC 84702 HCPCS outpatient 107 80.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 96.3 90 999999999 83.46 101.65 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUANTITATIVE" 3018470201_1 CDM 301 RC 84702 HCPCS outpatient 107 80.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 101.65 95 999999999 83.46 101.65 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUANTITATIVE" 3018470201_1 CDM 301 RC 84702 HCPCS outpatient 107 80.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 101.65 95 999999999 83.46 101.65 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUANTITATIVE" 3018470201_1 CDM 301 RC 84702 HCPCS outpatient 107 80.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 95.23 89 999999999 83.46 101.65 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUANTITATIVE" 3018470201_1 CDM 301 RC 84702 HCPCS outpatient 107 80.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 94.16 88 999999999 83.46 101.65 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUANTITATIVE" 3018470201_1 CDM 301 RC 84702 HCPCS outpatient 107 80.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 95.23 89 999999999 83.46 101.65 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUALITATIVE" 3018470301_1 CDM 301 RC 84703 HCPCS outpatient 101 75.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 90.9 90 999999999 78.78 95.95 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUALITATIVE" 3018470301_1 CDM 301 RC 84703 HCPCS outpatient 101 75.75 AETNA MCR ADV AETNA MCR ADV 78.78 78 999999999 78.78 95.95 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUALITATIVE" 3018470301_1 CDM 301 RC 84703 HCPCS outpatient 101 75.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 88.45 87.57 999999999 78.78 95.95 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUALITATIVE" 3018470301_1 CDM 301 RC 84703 HCPCS outpatient 101 75.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 85.92 85.07 999999999 78.78 95.95 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUALITATIVE" 3018470301_1 CDM 301 RC 84703 HCPCS outpatient 101 75.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 85.92 85.07 999999999 78.78 95.95 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUALITATIVE" 3018470301_1 CDM 301 RC 84703 HCPCS outpatient 101 75.75 MOLINA MCAID MOLINA MCAID 84.23 83.4 999999999 78.78 95.95 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUALITATIVE" 3018470301_1 CDM 301 RC 84703 HCPCS outpatient 101 75.75 MOLINA MCR ADV MOLINA MCR ADV 89.89 89 999999999 78.78 95.95 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUALITATIVE" 3018470301_1 CDM 301 RC 84703 HCPCS outpatient 101 75.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 89.89 89 999999999 78.78 95.95 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUALITATIVE" 3018470301_1 CDM 301 RC 84703 HCPCS outpatient 101 75.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 89.89 89 999999999 78.78 95.95 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUALITATIVE" 3018470301_1 CDM 301 RC 84703 HCPCS outpatient 101 75.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 90.9 90 999999999 78.78 95.95 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUALITATIVE" 3018470301_1 CDM 301 RC 84703 HCPCS outpatient 101 75.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 95.95 95 999999999 78.78 95.95 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUALITATIVE" 3018470301_1 CDM 301 RC 84703 HCPCS outpatient 101 75.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 95.95 95 999999999 78.78 95.95 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUALITATIVE" 3018470301_1 CDM 301 RC 84703 HCPCS outpatient 101 75.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 89.89 89 999999999 78.78 95.95 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUALITATIVE" 3018470301_1 CDM 301 RC 84703 HCPCS outpatient 101 75.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 88.88 88 999999999 78.78 95.95 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUALITATIVE" 3018470301_1 CDM 301 RC 84703 HCPCS outpatient 101 75.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 89.89 89 999999999 78.78 95.95 percent of total billed charges "DRUG TEST(S), DEFINITIVE, UTILIZING (1) DRUG IDENTIFICATION METHODS ABLE TO IDENTIFY INDIVIDUAL DRUGS AND DISTINGUISH BETWEEN STRUCTURAL ISOMERS (BUT NOT NECESSARILY STEREOISOMERS), INCLUDING, BUT NOT LIMITED TO GC/MS (ANY TYPE, SINGLE OR TANDEM) AND LC/M" 301G048002_1 CDM 301 RC G0480 HCPCS outpatient 220 165 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 198 90 999999999 171.6 209 percent of total billed charges "DRUG TEST(S), DEFINITIVE, UTILIZING (1) DRUG IDENTIFICATION METHODS ABLE TO IDENTIFY INDIVIDUAL DRUGS AND DISTINGUISH BETWEEN STRUCTURAL ISOMERS (BUT NOT NECESSARILY STEREOISOMERS), INCLUDING, BUT NOT LIMITED TO GC/MS (ANY TYPE, SINGLE OR TANDEM) AND LC/M" 301G048002_1 CDM 301 RC G0480 HCPCS outpatient 220 165 AETNA MCR ADV AETNA MCR ADV 171.6 78 999999999 171.6 209 percent of total billed charges "DRUG TEST(S), DEFINITIVE, UTILIZING (1) DRUG IDENTIFICATION METHODS ABLE TO IDENTIFY INDIVIDUAL DRUGS AND DISTINGUISH BETWEEN STRUCTURAL ISOMERS (BUT NOT NECESSARILY STEREOISOMERS), INCLUDING, BUT NOT LIMITED TO GC/MS (ANY TYPE, SINGLE OR TANDEM) AND LC/M" 301G048002_1 CDM 301 RC G0480 HCPCS outpatient 220 165 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 192.65 87.57 999999999 171.6 209 percent of total billed charges "DRUG TEST(S), DEFINITIVE, UTILIZING (1) DRUG IDENTIFICATION METHODS ABLE TO IDENTIFY INDIVIDUAL DRUGS AND DISTINGUISH BETWEEN STRUCTURAL ISOMERS (BUT NOT NECESSARILY STEREOISOMERS), INCLUDING, BUT NOT LIMITED TO GC/MS (ANY TYPE, SINGLE OR TANDEM) AND LC/M" 301G048002_1 CDM 301 RC G0480 HCPCS outpatient 220 165 COORDINATED CARE MCAID COORDINATED CARE MCAID 187.15 85.07 999999999 171.6 209 percent of total billed charges "DRUG TEST(S), DEFINITIVE, UTILIZING (1) DRUG IDENTIFICATION METHODS ABLE TO IDENTIFY INDIVIDUAL DRUGS AND DISTINGUISH BETWEEN STRUCTURAL ISOMERS (BUT NOT NECESSARILY STEREOISOMERS), INCLUDING, BUT NOT LIMITED TO GC/MS (ANY TYPE, SINGLE OR TANDEM) AND LC/M" 301G048002_1 CDM 301 RC G0480 HCPCS outpatient 220 165 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 187.15 85.07 999999999 171.6 209 percent of total billed charges "DRUG TEST(S), DEFINITIVE, UTILIZING (1) DRUG IDENTIFICATION METHODS ABLE TO IDENTIFY INDIVIDUAL DRUGS AND DISTINGUISH BETWEEN STRUCTURAL ISOMERS (BUT NOT NECESSARILY STEREOISOMERS), INCLUDING, BUT NOT LIMITED TO GC/MS (ANY TYPE, SINGLE OR TANDEM) AND LC/M" 301G048002_1 CDM 301 RC G0480 HCPCS outpatient 220 165 MOLINA MCAID MOLINA MCAID 183.48 83.4 999999999 171.6 209 percent of total billed charges "DRUG TEST(S), DEFINITIVE, UTILIZING (1) DRUG IDENTIFICATION METHODS ABLE TO IDENTIFY INDIVIDUAL DRUGS AND DISTINGUISH BETWEEN STRUCTURAL ISOMERS (BUT NOT NECESSARILY STEREOISOMERS), INCLUDING, BUT NOT LIMITED TO GC/MS (ANY TYPE, SINGLE OR TANDEM) AND LC/M" 301G048002_1 CDM 301 RC G0480 HCPCS outpatient 220 165 MOLINA MCR ADV MOLINA MCR ADV 195.8 89 999999999 171.6 209 percent of total billed charges "DRUG TEST(S), DEFINITIVE, UTILIZING (1) DRUG IDENTIFICATION METHODS ABLE TO IDENTIFY INDIVIDUAL DRUGS AND DISTINGUISH BETWEEN STRUCTURAL ISOMERS (BUT NOT NECESSARILY STEREOISOMERS), INCLUDING, BUT NOT LIMITED TO GC/MS (ANY TYPE, SINGLE OR TANDEM) AND LC/M" 301G048002_1 CDM 301 RC G0480 HCPCS outpatient 220 165 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 195.8 89 999999999 171.6 209 percent of total billed charges "DRUG TEST(S), DEFINITIVE, UTILIZING (1) DRUG IDENTIFICATION METHODS ABLE TO IDENTIFY INDIVIDUAL DRUGS AND DISTINGUISH BETWEEN STRUCTURAL ISOMERS (BUT NOT NECESSARILY STEREOISOMERS), INCLUDING, BUT NOT LIMITED TO GC/MS (ANY TYPE, SINGLE OR TANDEM) AND LC/M" 301G048002_1 CDM 301 RC G0480 HCPCS outpatient 220 165 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 195.8 89 999999999 171.6 209 percent of total billed charges "DRUG TEST(S), DEFINITIVE, UTILIZING (1) DRUG IDENTIFICATION METHODS ABLE TO IDENTIFY INDIVIDUAL DRUGS AND DISTINGUISH BETWEEN STRUCTURAL ISOMERS (BUT NOT NECESSARILY STEREOISOMERS), INCLUDING, BUT NOT LIMITED TO GC/MS (ANY TYPE, SINGLE OR TANDEM) AND LC/M" 301G048002_1 CDM 301 RC G0480 HCPCS outpatient 220 165 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 198 90 999999999 171.6 209 percent of total billed charges "DRUG TEST(S), DEFINITIVE, UTILIZING (1) DRUG IDENTIFICATION METHODS ABLE TO IDENTIFY INDIVIDUAL DRUGS AND DISTINGUISH BETWEEN STRUCTURAL ISOMERS (BUT NOT NECESSARILY STEREOISOMERS), INCLUDING, BUT NOT LIMITED TO GC/MS (ANY TYPE, SINGLE OR TANDEM) AND LC/M" 301G048002_1 CDM 301 RC G0480 HCPCS outpatient 220 165 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 209 95 999999999 171.6 209 percent of total billed charges "DRUG TEST(S), DEFINITIVE, UTILIZING (1) DRUG IDENTIFICATION METHODS ABLE TO IDENTIFY INDIVIDUAL DRUGS AND DISTINGUISH BETWEEN STRUCTURAL ISOMERS (BUT NOT NECESSARILY STEREOISOMERS), INCLUDING, BUT NOT LIMITED TO GC/MS (ANY TYPE, SINGLE OR TANDEM) AND LC/M" 301G048002_1 CDM 301 RC G0480 HCPCS outpatient 220 165 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 209 95 999999999 171.6 209 percent of total billed charges "DRUG TEST(S), DEFINITIVE, UTILIZING (1) DRUG IDENTIFICATION METHODS ABLE TO IDENTIFY INDIVIDUAL DRUGS AND DISTINGUISH BETWEEN STRUCTURAL ISOMERS (BUT NOT NECESSARILY STEREOISOMERS), INCLUDING, BUT NOT LIMITED TO GC/MS (ANY TYPE, SINGLE OR TANDEM) AND LC/M" 301G048002_1 CDM 301 RC G0480 HCPCS outpatient 220 165 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 195.8 89 999999999 171.6 209 percent of total billed charges "DRUG TEST(S), DEFINITIVE, UTILIZING (1) DRUG IDENTIFICATION METHODS ABLE TO IDENTIFY INDIVIDUAL DRUGS AND DISTINGUISH BETWEEN STRUCTURAL ISOMERS (BUT NOT NECESSARILY STEREOISOMERS), INCLUDING, BUT NOT LIMITED TO GC/MS (ANY TYPE, SINGLE OR TANDEM) AND LC/M" 301G048002_1 CDM 301 RC G0480 HCPCS outpatient 220 165 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 193.6 88 999999999 171.6 209 percent of total billed charges "DRUG TEST(S), DEFINITIVE, UTILIZING (1) DRUG IDENTIFICATION METHODS ABLE TO IDENTIFY INDIVIDUAL DRUGS AND DISTINGUISH BETWEEN STRUCTURAL ISOMERS (BUT NOT NECESSARILY STEREOISOMERS), INCLUDING, BUT NOT LIMITED TO GC/MS (ANY TYPE, SINGLE OR TANDEM) AND LC/M" 301G048002_1 CDM 301 RC G0480 HCPCS outpatient 220 165 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 195.8 89 999999999 171.6 209 percent of total billed charges "ALLERGEN SPECIFIC IGE; QUANTITATIVE OR SEMIQUANTITATIVE, CRUDE ALLERGEN EXTRACT, EACH" 3028600301_1 CDM 302 RC 86003 HCPCS outpatient 140 105 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 126 90 999999999 109.2 133 percent of total billed charges "ALLERGEN SPECIFIC IGE; QUANTITATIVE OR SEMIQUANTITATIVE, CRUDE ALLERGEN EXTRACT, EACH" 3028600301_1 CDM 302 RC 86003 HCPCS outpatient 140 105 AETNA MCR ADV AETNA MCR ADV 109.2 78 999999999 109.2 133 percent of total billed charges "ALLERGEN SPECIFIC IGE; QUANTITATIVE OR SEMIQUANTITATIVE, CRUDE ALLERGEN EXTRACT, EACH" 3028600301_1 CDM 302 RC 86003 HCPCS outpatient 140 105 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 122.6 87.57 999999999 109.2 133 percent of total billed charges "ALLERGEN SPECIFIC IGE; QUANTITATIVE OR SEMIQUANTITATIVE, CRUDE ALLERGEN EXTRACT, EACH" 3028600301_1 CDM 302 RC 86003 HCPCS outpatient 140 105 COORDINATED CARE MCAID COORDINATED CARE MCAID 119.1 85.07 999999999 109.2 133 percent of total billed charges "ALLERGEN SPECIFIC IGE; QUANTITATIVE OR SEMIQUANTITATIVE, CRUDE ALLERGEN EXTRACT, EACH" 3028600301_1 CDM 302 RC 86003 HCPCS outpatient 140 105 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 119.1 85.07 999999999 109.2 133 percent of total billed charges "ALLERGEN SPECIFIC IGE; QUANTITATIVE OR SEMIQUANTITATIVE, CRUDE ALLERGEN EXTRACT, EACH" 3028600301_1 CDM 302 RC 86003 HCPCS outpatient 140 105 MOLINA MCAID MOLINA MCAID 116.76 83.4 999999999 109.2 133 percent of total billed charges "ALLERGEN SPECIFIC IGE; QUANTITATIVE OR SEMIQUANTITATIVE, CRUDE ALLERGEN EXTRACT, EACH" 3028600301_1 CDM 302 RC 86003 HCPCS outpatient 140 105 MOLINA MCR ADV MOLINA MCR ADV 124.6 89 999999999 109.2 133 percent of total billed charges "ALLERGEN SPECIFIC IGE; QUANTITATIVE OR SEMIQUANTITATIVE, CRUDE ALLERGEN EXTRACT, EACH" 3028600301_1 CDM 302 RC 86003 HCPCS outpatient 140 105 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 124.6 89 999999999 109.2 133 percent of total billed charges "ALLERGEN SPECIFIC IGE; QUANTITATIVE OR SEMIQUANTITATIVE, CRUDE ALLERGEN EXTRACT, EACH" 3028600301_1 CDM 302 RC 86003 HCPCS outpatient 140 105 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 124.6 89 999999999 109.2 133 percent of total billed charges "ALLERGEN SPECIFIC IGE; QUANTITATIVE OR SEMIQUANTITATIVE, CRUDE ALLERGEN EXTRACT, EACH" 3028600301_1 CDM 302 RC 86003 HCPCS outpatient 140 105 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 126 90 999999999 109.2 133 percent of total billed charges "ALLERGEN SPECIFIC IGE; QUANTITATIVE OR SEMIQUANTITATIVE, CRUDE ALLERGEN EXTRACT, EACH" 3028600301_1 CDM 302 RC 86003 HCPCS outpatient 140 105 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 133 95 999999999 109.2 133 percent of total billed charges "ALLERGEN SPECIFIC IGE; QUANTITATIVE OR SEMIQUANTITATIVE, CRUDE ALLERGEN EXTRACT, EACH" 3028600301_1 CDM 302 RC 86003 HCPCS outpatient 140 105 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 133 95 999999999 109.2 133 percent of total billed charges "ALLERGEN SPECIFIC IGE; QUANTITATIVE OR SEMIQUANTITATIVE, CRUDE ALLERGEN EXTRACT, EACH" 3028600301_1 CDM 302 RC 86003 HCPCS outpatient 140 105 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 124.6 89 999999999 109.2 133 percent of total billed charges "ALLERGEN SPECIFIC IGE; QUANTITATIVE OR SEMIQUANTITATIVE, CRUDE ALLERGEN EXTRACT, EACH" 3028600301_1 CDM 302 RC 86003 HCPCS outpatient 140 105 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 123.2 88 999999999 109.2 133 percent of total billed charges "ALLERGEN SPECIFIC IGE; QUANTITATIVE OR SEMIQUANTITATIVE, CRUDE ALLERGEN EXTRACT, EACH" 3028600301_1 CDM 302 RC 86003 HCPCS outpatient 140 105 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 124.6 89 999999999 109.2 133 percent of total billed charges "ALLERGEN SPECIFIC IGE; QUANTITATIVE OR SEMIQUANTITATIVE, CRUDE ALLERGEN EXTRACT, EACH" 30286003AV_1 CDM 302 RC 86003 HCPCS outpatient 140 105 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 126 90 999999999 109.2 133 percent of total billed charges "ALLERGEN SPECIFIC IGE; QUANTITATIVE OR SEMIQUANTITATIVE, CRUDE ALLERGEN EXTRACT, EACH" 30286003AV_1 CDM 302 RC 86003 HCPCS outpatient 140 105 AETNA MCR ADV AETNA MCR ADV 109.2 78 999999999 109.2 133 percent of total billed charges "ALLERGEN SPECIFIC IGE; QUANTITATIVE OR SEMIQUANTITATIVE, CRUDE ALLERGEN EXTRACT, EACH" 30286003AV_1 CDM 302 RC 86003 HCPCS outpatient 140 105 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 122.6 87.57 999999999 109.2 133 percent of total billed charges "ALLERGEN SPECIFIC IGE; QUANTITATIVE OR SEMIQUANTITATIVE, CRUDE ALLERGEN EXTRACT, EACH" 30286003AV_1 CDM 302 RC 86003 HCPCS outpatient 140 105 COORDINATED CARE MCAID COORDINATED CARE MCAID 119.1 85.07 999999999 109.2 133 percent of total billed charges "ALLERGEN SPECIFIC IGE; QUANTITATIVE OR SEMIQUANTITATIVE, CRUDE ALLERGEN EXTRACT, EACH" 30286003AV_1 CDM 302 RC 86003 HCPCS outpatient 140 105 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 119.1 85.07 999999999 109.2 133 percent of total billed charges "ALLERGEN SPECIFIC IGE; QUANTITATIVE OR SEMIQUANTITATIVE, CRUDE ALLERGEN EXTRACT, EACH" 30286003AV_1 CDM 302 RC 86003 HCPCS outpatient 140 105 MOLINA MCAID MOLINA MCAID 116.76 83.4 999999999 109.2 133 percent of total billed charges "ALLERGEN SPECIFIC IGE; QUANTITATIVE OR SEMIQUANTITATIVE, CRUDE ALLERGEN EXTRACT, EACH" 30286003AV_1 CDM 302 RC 86003 HCPCS outpatient 140 105 MOLINA MCR ADV MOLINA MCR ADV 124.6 89 999999999 109.2 133 percent of total billed charges "ALLERGEN SPECIFIC IGE; QUANTITATIVE OR SEMIQUANTITATIVE, CRUDE ALLERGEN EXTRACT, EACH" 30286003AV_1 CDM 302 RC 86003 HCPCS outpatient 140 105 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 124.6 89 999999999 109.2 133 percent of total billed charges "ALLERGEN SPECIFIC IGE; QUANTITATIVE OR SEMIQUANTITATIVE, CRUDE ALLERGEN EXTRACT, EACH" 30286003AV_1 CDM 302 RC 86003 HCPCS outpatient 140 105 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 124.6 89 999999999 109.2 133 percent of total billed charges "ALLERGEN SPECIFIC IGE; QUANTITATIVE OR SEMIQUANTITATIVE, CRUDE ALLERGEN EXTRACT, EACH" 30286003AV_1 CDM 302 RC 86003 HCPCS outpatient 140 105 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 126 90 999999999 109.2 133 percent of total billed charges "ALLERGEN SPECIFIC IGE; QUANTITATIVE OR SEMIQUANTITATIVE, CRUDE ALLERGEN EXTRACT, EACH" 30286003AV_1 CDM 302 RC 86003 HCPCS outpatient 140 105 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 133 95 999999999 109.2 133 percent of total billed charges "ALLERGEN SPECIFIC IGE; QUANTITATIVE OR SEMIQUANTITATIVE, CRUDE ALLERGEN EXTRACT, EACH" 30286003AV_1 CDM 302 RC 86003 HCPCS outpatient 140 105 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 133 95 999999999 109.2 133 percent of total billed charges "ALLERGEN SPECIFIC IGE; QUANTITATIVE OR SEMIQUANTITATIVE, CRUDE ALLERGEN EXTRACT, EACH" 30286003AV_1 CDM 302 RC 86003 HCPCS outpatient 140 105 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 124.6 89 999999999 109.2 133 percent of total billed charges "ALLERGEN SPECIFIC IGE; QUANTITATIVE OR SEMIQUANTITATIVE, CRUDE ALLERGEN EXTRACT, EACH" 30286003AV_1 CDM 302 RC 86003 HCPCS outpatient 140 105 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 123.2 88 999999999 109.2 133 percent of total billed charges "ALLERGEN SPECIFIC IGE; QUANTITATIVE OR SEMIQUANTITATIVE, CRUDE ALLERGEN EXTRACT, EACH" 30286003AV_1 CDM 302 RC 86003 HCPCS outpatient 140 105 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 124.6 89 999999999 109.2 133 percent of total billed charges ANTINUCLEAR ANTIBODIES (ANA) 3028603804_1 CDM 302 RC 86038 HCPCS outpatient 100 75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 90 90 999999999 78 95 percent of total billed charges ANTINUCLEAR ANTIBODIES (ANA) 3028603804_1 CDM 302 RC 86038 HCPCS outpatient 100 75 AETNA MCR ADV AETNA MCR ADV 78 78 999999999 78 95 percent of total billed charges ANTINUCLEAR ANTIBODIES (ANA) 3028603804_1 CDM 302 RC 86038 HCPCS outpatient 100 75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 87.57 87.57 999999999 78 95 percent of total billed charges ANTINUCLEAR ANTIBODIES (ANA) 3028603804_1 CDM 302 RC 86038 HCPCS outpatient 100 75 COORDINATED CARE MCAID COORDINATED CARE MCAID 85.07 85.07 999999999 78 95 percent of total billed charges ANTINUCLEAR ANTIBODIES (ANA) 3028603804_1 CDM 302 RC 86038 HCPCS outpatient 100 75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 85.07 85.07 999999999 78 95 percent of total billed charges ANTINUCLEAR ANTIBODIES (ANA) 3028603804_1 CDM 302 RC 86038 HCPCS outpatient 100 75 MOLINA MCAID MOLINA MCAID 83.4 83.4 999999999 78 95 percent of total billed charges ANTINUCLEAR ANTIBODIES (ANA) 3028603804_1 CDM 302 RC 86038 HCPCS outpatient 100 75 MOLINA MCR ADV MOLINA MCR ADV 89 89 999999999 78 95 percent of total billed charges ANTINUCLEAR ANTIBODIES (ANA) 3028603804_1 CDM 302 RC 86038 HCPCS outpatient 100 75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 89 89 999999999 78 95 percent of total billed charges ANTINUCLEAR ANTIBODIES (ANA) 3028603804_1 CDM 302 RC 86038 HCPCS outpatient 100 75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 89 89 999999999 78 95 percent of total billed charges ANTINUCLEAR ANTIBODIES (ANA) 3028603804_1 CDM 302 RC 86038 HCPCS outpatient 100 75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 90 90 999999999 78 95 percent of total billed charges ANTINUCLEAR ANTIBODIES (ANA) 3028603804_1 CDM 302 RC 86038 HCPCS outpatient 100 75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 95 95 999999999 78 95 percent of total billed charges ANTINUCLEAR ANTIBODIES (ANA) 3028603804_1 CDM 302 RC 86038 HCPCS outpatient 100 75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 95 95 999999999 78 95 percent of total billed charges ANTINUCLEAR ANTIBODIES (ANA) 3028603804_1 CDM 302 RC 86038 HCPCS outpatient 100 75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 89 89 999999999 78 95 percent of total billed charges ANTINUCLEAR ANTIBODIES (ANA) 3028603804_1 CDM 302 RC 86038 HCPCS outpatient 100 75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 88 88 999999999 78 95 percent of total billed charges ANTINUCLEAR ANTIBODIES (ANA) 3028603804_1 CDM 302 RC 86038 HCPCS outpatient 100 75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 89 89 999999999 78 95 percent of total billed charges ANTINUCLEAR ANTIBODIES (ANA); TITER 3028603902_1 CDM 302 RC 86039 HCPCS outpatient 119 89.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 107.1 90 999999999 92.82 113.05 percent of total billed charges ANTINUCLEAR ANTIBODIES (ANA); TITER 3028603902_1 CDM 302 RC 86039 HCPCS outpatient 119 89.25 AETNA MCR ADV AETNA MCR ADV 92.82 78 999999999 92.82 113.05 percent of total billed charges ANTINUCLEAR ANTIBODIES (ANA); TITER 3028603902_1 CDM 302 RC 86039 HCPCS outpatient 119 89.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 104.21 87.57 999999999 92.82 113.05 percent of total billed charges ANTINUCLEAR ANTIBODIES (ANA); TITER 3028603902_1 CDM 302 RC 86039 HCPCS outpatient 119 89.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 101.23 85.07 999999999 92.82 113.05 percent of total billed charges ANTINUCLEAR ANTIBODIES (ANA); TITER 3028603902_1 CDM 302 RC 86039 HCPCS outpatient 119 89.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 101.23 85.07 999999999 92.82 113.05 percent of total billed charges ANTINUCLEAR ANTIBODIES (ANA); TITER 3028603902_1 CDM 302 RC 86039 HCPCS outpatient 119 89.25 MOLINA MCAID MOLINA MCAID 99.25 83.4 999999999 92.82 113.05 percent of total billed charges ANTINUCLEAR ANTIBODIES (ANA); TITER 3028603902_1 CDM 302 RC 86039 HCPCS outpatient 119 89.25 MOLINA MCR ADV MOLINA MCR ADV 105.91 89 999999999 92.82 113.05 percent of total billed charges ANTINUCLEAR ANTIBODIES (ANA); TITER 3028603902_1 CDM 302 RC 86039 HCPCS outpatient 119 89.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 105.91 89 999999999 92.82 113.05 percent of total billed charges ANTINUCLEAR ANTIBODIES (ANA); TITER 3028603902_1 CDM 302 RC 86039 HCPCS outpatient 119 89.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 105.91 89 999999999 92.82 113.05 percent of total billed charges ANTINUCLEAR ANTIBODIES (ANA); TITER 3028603902_1 CDM 302 RC 86039 HCPCS outpatient 119 89.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 107.1 90 999999999 92.82 113.05 percent of total billed charges ANTINUCLEAR ANTIBODIES (ANA); TITER 3028603902_1 CDM 302 RC 86039 HCPCS outpatient 119 89.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 113.05 95 999999999 92.82 113.05 percent of total billed charges ANTINUCLEAR ANTIBODIES (ANA); TITER 3028603902_1 CDM 302 RC 86039 HCPCS outpatient 119 89.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 113.05 95 999999999 92.82 113.05 percent of total billed charges ANTINUCLEAR ANTIBODIES (ANA); TITER 3028603902_1 CDM 302 RC 86039 HCPCS outpatient 119 89.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 105.91 89 999999999 92.82 113.05 percent of total billed charges ANTINUCLEAR ANTIBODIES (ANA); TITER 3028603902_1 CDM 302 RC 86039 HCPCS outpatient 119 89.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 104.72 88 999999999 92.82 113.05 percent of total billed charges ANTINUCLEAR ANTIBODIES (ANA); TITER 3028603902_1 CDM 302 RC 86039 HCPCS outpatient 119 89.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 105.91 89 999999999 92.82 113.05 percent of total billed charges ANTISTREPTOLYSIN 0; TITER 3028606001_1 CDM 302 RC 86060 HCPCS outpatient 62 46.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 55.8 90 999999999 48.36 58.9 percent of total billed charges ANTISTREPTOLYSIN 0; TITER 3028606001_1 CDM 302 RC 86060 HCPCS outpatient 62 46.5 AETNA MCR ADV AETNA MCR ADV 48.36 78 999999999 48.36 58.9 percent of total billed charges ANTISTREPTOLYSIN 0; TITER 3028606001_1 CDM 302 RC 86060 HCPCS outpatient 62 46.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 54.29 87.57 999999999 48.36 58.9 percent of total billed charges ANTISTREPTOLYSIN 0; TITER 3028606001_1 CDM 302 RC 86060 HCPCS outpatient 62 46.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 52.74 85.07 999999999 48.36 58.9 percent of total billed charges ANTISTREPTOLYSIN 0; TITER 3028606001_1 CDM 302 RC 86060 HCPCS outpatient 62 46.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 52.74 85.07 999999999 48.36 58.9 percent of total billed charges ANTISTREPTOLYSIN 0; TITER 3028606001_1 CDM 302 RC 86060 HCPCS outpatient 62 46.5 MOLINA MCAID MOLINA MCAID 51.71 83.4 999999999 48.36 58.9 percent of total billed charges ANTISTREPTOLYSIN 0; TITER 3028606001_1 CDM 302 RC 86060 HCPCS outpatient 62 46.5 MOLINA MCR ADV MOLINA MCR ADV 55.18 89 999999999 48.36 58.9 percent of total billed charges ANTISTREPTOLYSIN 0; TITER 3028606001_1 CDM 302 RC 86060 HCPCS outpatient 62 46.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 55.18 89 999999999 48.36 58.9 percent of total billed charges ANTISTREPTOLYSIN 0; TITER 3028606001_1 CDM 302 RC 86060 HCPCS outpatient 62 46.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 55.18 89 999999999 48.36 58.9 percent of total billed charges ANTISTREPTOLYSIN 0; TITER 3028606001_1 CDM 302 RC 86060 HCPCS outpatient 62 46.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 55.8 90 999999999 48.36 58.9 percent of total billed charges ANTISTREPTOLYSIN 0; TITER 3028606001_1 CDM 302 RC 86060 HCPCS outpatient 62 46.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 58.9 95 999999999 48.36 58.9 percent of total billed charges ANTISTREPTOLYSIN 0; TITER 3028606001_1 CDM 302 RC 86060 HCPCS outpatient 62 46.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 58.9 95 999999999 48.36 58.9 percent of total billed charges ANTISTREPTOLYSIN 0; TITER 3028606001_1 CDM 302 RC 86060 HCPCS outpatient 62 46.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 55.18 89 999999999 48.36 58.9 percent of total billed charges ANTISTREPTOLYSIN 0; TITER 3028606001_1 CDM 302 RC 86060 HCPCS outpatient 62 46.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 54.56 88 999999999 48.36 58.9 percent of total billed charges ANTISTREPTOLYSIN 0; TITER 3028606001_1 CDM 302 RC 86060 HCPCS outpatient 62 46.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 55.18 89 999999999 48.36 58.9 percent of total billed charges C-REACTIVE PROTEIN 3028614001_1 CDM 302 RC 86140 HCPCS outpatient 98 73.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 85.82 87.57 999999999 76.44 93.1 percent of total billed charges C-REACTIVE PROTEIN 3028614001_1 CDM 302 RC 86140 HCPCS outpatient 98 73.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 83.37 85.07 999999999 76.44 93.1 percent of total billed charges C-REACTIVE PROTEIN 3028614001_1 CDM 302 RC 86140 HCPCS outpatient 98 73.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 83.37 85.07 999999999 76.44 93.1 percent of total billed charges C-REACTIVE PROTEIN 3028614001_1 CDM 302 RC 86140 HCPCS outpatient 98 73.5 MOLINA MCAID MOLINA MCAID 81.73 83.4 999999999 76.44 93.1 percent of total billed charges C-REACTIVE PROTEIN 3028614001_1 CDM 302 RC 86140 HCPCS outpatient 98 73.5 MOLINA MCR ADV MOLINA MCR ADV 87.22 89 999999999 76.44 93.1 percent of total billed charges C-REACTIVE PROTEIN 3028614001_1 CDM 302 RC 86140 HCPCS outpatient 98 73.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 87.22 89 999999999 76.44 93.1 percent of total billed charges C-REACTIVE PROTEIN 3028614001_1 CDM 302 RC 86140 HCPCS outpatient 98 73.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 87.22 89 999999999 76.44 93.1 percent of total billed charges C-REACTIVE PROTEIN 3028614001_1 CDM 302 RC 86140 HCPCS outpatient 98 73.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 88.2 90 999999999 76.44 93.1 percent of total billed charges C-REACTIVE PROTEIN 3028614001_1 CDM 302 RC 86140 HCPCS outpatient 98 73.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 93.1 95 999999999 76.44 93.1 percent of total billed charges C-REACTIVE PROTEIN 3028614001_1 CDM 302 RC 86140 HCPCS outpatient 98 73.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 93.1 95 999999999 76.44 93.1 percent of total billed charges C-REACTIVE PROTEIN 3028614001_1 CDM 302 RC 86140 HCPCS outpatient 98 73.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 87.22 89 999999999 76.44 93.1 percent of total billed charges C-REACTIVE PROTEIN 3028614001_1 CDM 302 RC 86140 HCPCS outpatient 98 73.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 86.24 88 999999999 76.44 93.1 percent of total billed charges C-REACTIVE PROTEIN 3028614001_1 CDM 302 RC 86140 HCPCS outpatient 98 73.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 87.22 89 999999999 76.44 93.1 percent of total billed charges C-REACTIVE PROTEIN 3028614001_1 CDM 302 RC 86140 HCPCS outpatient 98 73.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 88.2 90 999999999 76.44 93.1 percent of total billed charges C-REACTIVE PROTEIN 3028614001_1 CDM 302 RC 86140 HCPCS outpatient 98 73.5 AETNA MCR ADV AETNA MCR ADV 76.44 78 999999999 76.44 93.1 percent of total billed charges C-REACTIVE PROTEIN; HIGH SENSITIVITY (HSCRP) 3028614101_1 CDM 302 RC 86141 HCPCS outpatient 89 66.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 80.1 90 999999999 69.42 84.55 percent of total billed charges C-REACTIVE PROTEIN; HIGH SENSITIVITY (HSCRP) 3028614101_1 CDM 302 RC 86141 HCPCS outpatient 89 66.75 AETNA MCR ADV AETNA MCR ADV 69.42 78 999999999 69.42 84.55 percent of total billed charges C-REACTIVE PROTEIN; HIGH SENSITIVITY (HSCRP) 3028614101_1 CDM 302 RC 86141 HCPCS outpatient 89 66.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 77.94 87.57 999999999 69.42 84.55 percent of total billed charges C-REACTIVE PROTEIN; HIGH SENSITIVITY (HSCRP) 3028614101_1 CDM 302 RC 86141 HCPCS outpatient 89 66.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 75.71 85.07 999999999 69.42 84.55 percent of total billed charges C-REACTIVE PROTEIN; HIGH SENSITIVITY (HSCRP) 3028614101_1 CDM 302 RC 86141 HCPCS outpatient 89 66.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 75.71 85.07 999999999 69.42 84.55 percent of total billed charges C-REACTIVE PROTEIN; HIGH SENSITIVITY (HSCRP) 3028614101_1 CDM 302 RC 86141 HCPCS outpatient 89 66.75 MOLINA MCAID MOLINA MCAID 74.23 83.4 999999999 69.42 84.55 percent of total billed charges C-REACTIVE PROTEIN; HIGH SENSITIVITY (HSCRP) 3028614101_1 CDM 302 RC 86141 HCPCS outpatient 89 66.75 MOLINA MCR ADV MOLINA MCR ADV 79.21 89 999999999 69.42 84.55 percent of total billed charges C-REACTIVE PROTEIN; HIGH SENSITIVITY (HSCRP) 3028614101_1 CDM 302 RC 86141 HCPCS outpatient 89 66.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 79.21 89 999999999 69.42 84.55 percent of total billed charges C-REACTIVE PROTEIN; HIGH SENSITIVITY (HSCRP) 3028614101_1 CDM 302 RC 86141 HCPCS outpatient 89 66.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 79.21 89 999999999 69.42 84.55 percent of total billed charges C-REACTIVE PROTEIN; HIGH SENSITIVITY (HSCRP) 3028614101_1 CDM 302 RC 86141 HCPCS outpatient 89 66.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 80.1 90 999999999 69.42 84.55 percent of total billed charges C-REACTIVE PROTEIN; HIGH SENSITIVITY (HSCRP) 3028614101_1 CDM 302 RC 86141 HCPCS outpatient 89 66.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 84.55 95 999999999 69.42 84.55 percent of total billed charges C-REACTIVE PROTEIN; HIGH SENSITIVITY (HSCRP) 3028614101_1 CDM 302 RC 86141 HCPCS outpatient 89 66.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 84.55 95 999999999 69.42 84.55 percent of total billed charges C-REACTIVE PROTEIN; HIGH SENSITIVITY (HSCRP) 3028614101_1 CDM 302 RC 86141 HCPCS outpatient 89 66.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 79.21 89 999999999 69.42 84.55 percent of total billed charges C-REACTIVE PROTEIN; HIGH SENSITIVITY (HSCRP) 3028614101_1 CDM 302 RC 86141 HCPCS outpatient 89 66.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 78.32 88 999999999 69.42 84.55 percent of total billed charges C-REACTIVE PROTEIN; HIGH SENSITIVITY (HSCRP) 3028614101_1 CDM 302 RC 86141 HCPCS outpatient 89 66.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 79.21 89 999999999 69.42 84.55 percent of total billed charges COLD AGGLUTININ; TITER 3028615701_1 CDM 302 RC 86157 HCPCS outpatient 101 75.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 90.9 90 999999999 78.78 95.95 percent of total billed charges COLD AGGLUTININ; TITER 3028615701_1 CDM 302 RC 86157 HCPCS outpatient 101 75.75 AETNA MCR ADV AETNA MCR ADV 78.78 78 999999999 78.78 95.95 percent of total billed charges COLD AGGLUTININ; TITER 3028615701_1 CDM 302 RC 86157 HCPCS outpatient 101 75.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 88.45 87.57 999999999 78.78 95.95 percent of total billed charges COLD AGGLUTININ; TITER 3028615701_1 CDM 302 RC 86157 HCPCS outpatient 101 75.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 85.92 85.07 999999999 78.78 95.95 percent of total billed charges COLD AGGLUTININ; TITER 3028615701_1 CDM 302 RC 86157 HCPCS outpatient 101 75.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 85.92 85.07 999999999 78.78 95.95 percent of total billed charges COLD AGGLUTININ; TITER 3028615701_1 CDM 302 RC 86157 HCPCS outpatient 101 75.75 MOLINA MCAID MOLINA MCAID 84.23 83.4 999999999 78.78 95.95 percent of total billed charges COLD AGGLUTININ; TITER 3028615701_1 CDM 302 RC 86157 HCPCS outpatient 101 75.75 MOLINA MCR ADV MOLINA MCR ADV 89.89 89 999999999 78.78 95.95 percent of total billed charges COLD AGGLUTININ; TITER 3028615701_1 CDM 302 RC 86157 HCPCS outpatient 101 75.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 89.89 89 999999999 78.78 95.95 percent of total billed charges COLD AGGLUTININ; TITER 3028615701_1 CDM 302 RC 86157 HCPCS outpatient 101 75.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 89.89 89 999999999 78.78 95.95 percent of total billed charges COLD AGGLUTININ; TITER 3028615701_1 CDM 302 RC 86157 HCPCS outpatient 101 75.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 90.9 90 999999999 78.78 95.95 percent of total billed charges COLD AGGLUTININ; TITER 3028615701_1 CDM 302 RC 86157 HCPCS outpatient 101 75.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 95.95 95 999999999 78.78 95.95 percent of total billed charges COLD AGGLUTININ; TITER 3028615701_1 CDM 302 RC 86157 HCPCS outpatient 101 75.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 95.95 95 999999999 78.78 95.95 percent of total billed charges COLD AGGLUTININ; TITER 3028615701_1 CDM 302 RC 86157 HCPCS outpatient 101 75.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 89.89 89 999999999 78.78 95.95 percent of total billed charges COLD AGGLUTININ; TITER 3028615701_1 CDM 302 RC 86157 HCPCS outpatient 101 75.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 88.88 88 999999999 78.78 95.95 percent of total billed charges COLD AGGLUTININ; TITER 3028615701_1 CDM 302 RC 86157 HCPCS outpatient 101 75.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 89.89 89 999999999 78.78 95.95 percent of total billed charges "COMPLEMENT; ANTIGEN, EACH COMPONENT" 3028616003_1 CDM 302 RC 86160 HCPCS outpatient 158 118.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 142.2 90 999999999 123.24 150.1 percent of total billed charges "COMPLEMENT; ANTIGEN, EACH COMPONENT" 3028616003_1 CDM 302 RC 86160 HCPCS outpatient 158 118.5 AETNA MCR ADV AETNA MCR ADV 123.24 78 999999999 123.24 150.1 percent of total billed charges "COMPLEMENT; ANTIGEN, EACH COMPONENT" 3028616003_1 CDM 302 RC 86160 HCPCS outpatient 158 118.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 138.36 87.57 999999999 123.24 150.1 percent of total billed charges "COMPLEMENT; ANTIGEN, EACH COMPONENT" 3028616003_1 CDM 302 RC 86160 HCPCS outpatient 158 118.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 134.41 85.07 999999999 123.24 150.1 percent of total billed charges "COMPLEMENT; ANTIGEN, EACH COMPONENT" 3028616003_1 CDM 302 RC 86160 HCPCS outpatient 158 118.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 134.41 85.07 999999999 123.24 150.1 percent of total billed charges "COMPLEMENT; ANTIGEN, EACH COMPONENT" 3028616003_1 CDM 302 RC 86160 HCPCS outpatient 158 118.5 MOLINA MCAID MOLINA MCAID 131.77 83.4 999999999 123.24 150.1 percent of total billed charges "COMPLEMENT; ANTIGEN, EACH COMPONENT" 3028616003_1 CDM 302 RC 86160 HCPCS outpatient 158 118.5 MOLINA MCR ADV MOLINA MCR ADV 140.62 89 999999999 123.24 150.1 percent of total billed charges "COMPLEMENT; ANTIGEN, EACH COMPONENT" 3028616003_1 CDM 302 RC 86160 HCPCS outpatient 158 118.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 140.62 89 999999999 123.24 150.1 percent of total billed charges "COMPLEMENT; ANTIGEN, EACH COMPONENT" 3028616003_1 CDM 302 RC 86160 HCPCS outpatient 158 118.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 140.62 89 999999999 123.24 150.1 percent of total billed charges "COMPLEMENT; ANTIGEN, EACH COMPONENT" 3028616003_1 CDM 302 RC 86160 HCPCS outpatient 158 118.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 142.2 90 999999999 123.24 150.1 percent of total billed charges "COMPLEMENT; ANTIGEN, EACH COMPONENT" 3028616003_1 CDM 302 RC 86160 HCPCS outpatient 158 118.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 150.1 95 999999999 123.24 150.1 percent of total billed charges "COMPLEMENT; ANTIGEN, EACH COMPONENT" 3028616003_1 CDM 302 RC 86160 HCPCS outpatient 158 118.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 150.1 95 999999999 123.24 150.1 percent of total billed charges "COMPLEMENT; ANTIGEN, EACH COMPONENT" 3028616003_1 CDM 302 RC 86160 HCPCS outpatient 158 118.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 140.62 89 999999999 123.24 150.1 percent of total billed charges "COMPLEMENT; ANTIGEN, EACH COMPONENT" 3028616003_1 CDM 302 RC 86160 HCPCS outpatient 158 118.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 139.04 88 999999999 123.24 150.1 percent of total billed charges "COMPLEMENT; ANTIGEN, EACH COMPONENT" 3028616003_1 CDM 302 RC 86160 HCPCS outpatient 158 118.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 140.62 89 999999999 123.24 150.1 percent of total billed charges "CYCLIC CITRULLINATED PEPTIDE (CCP), ANTIBODY" 3028620004_1 CDM 302 RC 86200 HCPCS outpatient 144 108 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 129.6 90 999999999 112.32 136.8 percent of total billed charges "CYCLIC CITRULLINATED PEPTIDE (CCP), ANTIBODY" 3028620004_1 CDM 302 RC 86200 HCPCS outpatient 144 108 AETNA MCR ADV AETNA MCR ADV 112.32 78 999999999 112.32 136.8 percent of total billed charges "CYCLIC CITRULLINATED PEPTIDE (CCP), ANTIBODY" 3028620004_1 CDM 302 RC 86200 HCPCS outpatient 144 108 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 126.1 87.57 999999999 112.32 136.8 percent of total billed charges "CYCLIC CITRULLINATED PEPTIDE (CCP), ANTIBODY" 3028620004_1 CDM 302 RC 86200 HCPCS outpatient 144 108 COORDINATED CARE MCAID COORDINATED CARE MCAID 122.5 85.07 999999999 112.32 136.8 percent of total billed charges "CYCLIC CITRULLINATED PEPTIDE (CCP), ANTIBODY" 3028620004_1 CDM 302 RC 86200 HCPCS outpatient 144 108 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 122.5 85.07 999999999 112.32 136.8 percent of total billed charges "CYCLIC CITRULLINATED PEPTIDE (CCP), ANTIBODY" 3028620004_1 CDM 302 RC 86200 HCPCS outpatient 144 108 MOLINA MCAID MOLINA MCAID 120.1 83.4 999999999 112.32 136.8 percent of total billed charges "CYCLIC CITRULLINATED PEPTIDE (CCP), ANTIBODY" 3028620004_1 CDM 302 RC 86200 HCPCS outpatient 144 108 MOLINA MCR ADV MOLINA MCR ADV 128.16 89 999999999 112.32 136.8 percent of total billed charges "CYCLIC CITRULLINATED PEPTIDE (CCP), ANTIBODY" 3028620004_1 CDM 302 RC 86200 HCPCS outpatient 144 108 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 128.16 89 999999999 112.32 136.8 percent of total billed charges "CYCLIC CITRULLINATED PEPTIDE (CCP), ANTIBODY" 3028620004_1 CDM 302 RC 86200 HCPCS outpatient 144 108 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 128.16 89 999999999 112.32 136.8 percent of total billed charges "CYCLIC CITRULLINATED PEPTIDE (CCP), ANTIBODY" 3028620004_1 CDM 302 RC 86200 HCPCS outpatient 144 108 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 129.6 90 999999999 112.32 136.8 percent of total billed charges "CYCLIC CITRULLINATED PEPTIDE (CCP), ANTIBODY" 3028620004_1 CDM 302 RC 86200 HCPCS outpatient 144 108 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 136.8 95 999999999 112.32 136.8 percent of total billed charges "CYCLIC CITRULLINATED PEPTIDE (CCP), ANTIBODY" 3028620004_1 CDM 302 RC 86200 HCPCS outpatient 144 108 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 136.8 95 999999999 112.32 136.8 percent of total billed charges "CYCLIC CITRULLINATED PEPTIDE (CCP), ANTIBODY" 3028620004_1 CDM 302 RC 86200 HCPCS outpatient 144 108 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 128.16 89 999999999 112.32 136.8 percent of total billed charges "CYCLIC CITRULLINATED PEPTIDE (CCP), ANTIBODY" 3028620004_1 CDM 302 RC 86200 HCPCS outpatient 144 108 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 126.72 88 999999999 112.32 136.8 percent of total billed charges "CYCLIC CITRULLINATED PEPTIDE (CCP), ANTIBODY" 3028620004_1 CDM 302 RC 86200 HCPCS outpatient 144 108 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 128.16 89 999999999 112.32 136.8 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 15-3 (27.29)" 3028630001_1 CDM 302 RC 86300 HCPCS outpatient 233 174.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 209.7 90 999999999 181.74 221.35 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 15-3 (27.29)" 3028630001_1 CDM 302 RC 86300 HCPCS outpatient 233 174.75 AETNA MCR ADV AETNA MCR ADV 181.74 78 999999999 181.74 221.35 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 15-3 (27.29)" 3028630001_1 CDM 302 RC 86300 HCPCS outpatient 233 174.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 204.04 87.57 999999999 181.74 221.35 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 15-3 (27.29)" 3028630001_1 CDM 302 RC 86300 HCPCS outpatient 233 174.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 198.21 85.07 999999999 181.74 221.35 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 15-3 (27.29)" 3028630001_1 CDM 302 RC 86300 HCPCS outpatient 233 174.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 198.21 85.07 999999999 181.74 221.35 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 15-3 (27.29)" 3028630001_1 CDM 302 RC 86300 HCPCS outpatient 233 174.75 MOLINA MCAID MOLINA MCAID 194.32 83.4 999999999 181.74 221.35 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 15-3 (27.29)" 3028630001_1 CDM 302 RC 86300 HCPCS outpatient 233 174.75 MOLINA MCR ADV MOLINA MCR ADV 207.37 89 999999999 181.74 221.35 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 15-3 (27.29)" 3028630001_1 CDM 302 RC 86300 HCPCS outpatient 233 174.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 207.37 89 999999999 181.74 221.35 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 15-3 (27.29)" 3028630001_1 CDM 302 RC 86300 HCPCS outpatient 233 174.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 207.37 89 999999999 181.74 221.35 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 15-3 (27.29)" 3028630001_1 CDM 302 RC 86300 HCPCS outpatient 233 174.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 209.7 90 999999999 181.74 221.35 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 15-3 (27.29)" 3028630001_1 CDM 302 RC 86300 HCPCS outpatient 233 174.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 221.35 95 999999999 181.74 221.35 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 15-3 (27.29)" 3028630001_1 CDM 302 RC 86300 HCPCS outpatient 233 174.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 221.35 95 999999999 181.74 221.35 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 15-3 (27.29)" 3028630001_1 CDM 302 RC 86300 HCPCS outpatient 233 174.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 207.37 89 999999999 181.74 221.35 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 15-3 (27.29)" 3028630001_1 CDM 302 RC 86300 HCPCS outpatient 233 174.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 205.04 88 999999999 181.74 221.35 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 15-3 (27.29)" 3028630001_1 CDM 302 RC 86300 HCPCS outpatient 233 174.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 207.37 89 999999999 181.74 221.35 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 19-9" 3028630101_1 CDM 302 RC 86301 HCPCS outpatient 215 161.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 193.5 90 999999999 167.7 204.25 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 19-9" 3028630101_1 CDM 302 RC 86301 HCPCS outpatient 215 161.25 AETNA MCR ADV AETNA MCR ADV 167.7 78 999999999 167.7 204.25 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 19-9" 3028630101_1 CDM 302 RC 86301 HCPCS outpatient 215 161.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 188.28 87.57 999999999 167.7 204.25 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 19-9" 3028630101_1 CDM 302 RC 86301 HCPCS outpatient 215 161.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 182.9 85.07 999999999 167.7 204.25 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 19-9" 3028630101_1 CDM 302 RC 86301 HCPCS outpatient 215 161.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 182.9 85.07 999999999 167.7 204.25 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 19-9" 3028630101_1 CDM 302 RC 86301 HCPCS outpatient 215 161.25 MOLINA MCAID MOLINA MCAID 179.31 83.4 999999999 167.7 204.25 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 19-9" 3028630101_1 CDM 302 RC 86301 HCPCS outpatient 215 161.25 MOLINA MCR ADV MOLINA MCR ADV 191.35 89 999999999 167.7 204.25 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 19-9" 3028630101_1 CDM 302 RC 86301 HCPCS outpatient 215 161.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 191.35 89 999999999 167.7 204.25 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 19-9" 3028630101_1 CDM 302 RC 86301 HCPCS outpatient 215 161.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 191.35 89 999999999 167.7 204.25 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 19-9" 3028630101_1 CDM 302 RC 86301 HCPCS outpatient 215 161.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 193.5 90 999999999 167.7 204.25 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 19-9" 3028630101_1 CDM 302 RC 86301 HCPCS outpatient 215 161.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 204.25 95 999999999 167.7 204.25 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 19-9" 3028630101_1 CDM 302 RC 86301 HCPCS outpatient 215 161.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 204.25 95 999999999 167.7 204.25 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 19-9" 3028630101_1 CDM 302 RC 86301 HCPCS outpatient 215 161.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 191.35 89 999999999 167.7 204.25 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 19-9" 3028630101_1 CDM 302 RC 86301 HCPCS outpatient 215 161.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 189.2 88 999999999 167.7 204.25 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 19-9" 3028630101_1 CDM 302 RC 86301 HCPCS outpatient 215 161.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 191.35 89 999999999 167.7 204.25 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 125" 3028630401_1 CDM 302 RC 86304 HCPCS outpatient 184 138 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 165.6 90 999999999 143.52 174.8 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 125" 3028630401_1 CDM 302 RC 86304 HCPCS outpatient 184 138 AETNA MCR ADV AETNA MCR ADV 143.52 78 999999999 143.52 174.8 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 125" 3028630401_1 CDM 302 RC 86304 HCPCS outpatient 184 138 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 161.13 87.57 999999999 143.52 174.8 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 125" 3028630401_1 CDM 302 RC 86304 HCPCS outpatient 184 138 COORDINATED CARE MCAID COORDINATED CARE MCAID 156.53 85.07 999999999 143.52 174.8 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 125" 3028630401_1 CDM 302 RC 86304 HCPCS outpatient 184 138 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 156.53 85.07 999999999 143.52 174.8 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 125" 3028630401_1 CDM 302 RC 86304 HCPCS outpatient 184 138 MOLINA MCAID MOLINA MCAID 153.46 83.4 999999999 143.52 174.8 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 125" 3028630401_1 CDM 302 RC 86304 HCPCS outpatient 184 138 MOLINA MCR ADV MOLINA MCR ADV 163.76 89 999999999 143.52 174.8 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 125" 3028630401_1 CDM 302 RC 86304 HCPCS outpatient 184 138 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 163.76 89 999999999 143.52 174.8 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 125" 3028630401_1 CDM 302 RC 86304 HCPCS outpatient 184 138 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 163.76 89 999999999 143.52 174.8 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 125" 3028630401_1 CDM 302 RC 86304 HCPCS outpatient 184 138 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 165.6 90 999999999 143.52 174.8 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 125" 3028630401_1 CDM 302 RC 86304 HCPCS outpatient 184 138 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 174.8 95 999999999 143.52 174.8 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 125" 3028630401_1 CDM 302 RC 86304 HCPCS outpatient 184 138 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 174.8 95 999999999 143.52 174.8 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 125" 3028630401_1 CDM 302 RC 86304 HCPCS outpatient 184 138 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 163.76 89 999999999 143.52 174.8 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 125" 3028630401_1 CDM 302 RC 86304 HCPCS outpatient 184 138 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 161.92 88 999999999 143.52 174.8 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 125" 3028630401_1 CDM 302 RC 86304 HCPCS outpatient 184 138 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 163.76 89 999999999 143.52 174.8 percent of total billed charges HETEROPHILE ANTIBODIES; SCREENING 3028630801_1 CDM 302 RC 86308 HCPCS outpatient 104 78 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 93.6 90 999999999 81.12 98.8 percent of total billed charges HETEROPHILE ANTIBODIES; SCREENING 3028630801_1 CDM 302 RC 86308 HCPCS outpatient 104 78 AETNA MCR ADV AETNA MCR ADV 81.12 78 999999999 81.12 98.8 percent of total billed charges HETEROPHILE ANTIBODIES; SCREENING 3028630801_1 CDM 302 RC 86308 HCPCS outpatient 104 78 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 91.07 87.57 999999999 81.12 98.8 percent of total billed charges HETEROPHILE ANTIBODIES; SCREENING 3028630801_1 CDM 302 RC 86308 HCPCS outpatient 104 78 COORDINATED CARE MCAID COORDINATED CARE MCAID 88.47 85.07 999999999 81.12 98.8 percent of total billed charges HETEROPHILE ANTIBODIES; SCREENING 3028630801_1 CDM 302 RC 86308 HCPCS outpatient 104 78 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 88.47 85.07 999999999 81.12 98.8 percent of total billed charges HETEROPHILE ANTIBODIES; SCREENING 3028630801_1 CDM 302 RC 86308 HCPCS outpatient 104 78 MOLINA MCAID MOLINA MCAID 86.74 83.4 999999999 81.12 98.8 percent of total billed charges HETEROPHILE ANTIBODIES; SCREENING 3028630801_1 CDM 302 RC 86308 HCPCS outpatient 104 78 MOLINA MCR ADV MOLINA MCR ADV 92.56 89 999999999 81.12 98.8 percent of total billed charges HETEROPHILE ANTIBODIES; SCREENING 3028630801_1 CDM 302 RC 86308 HCPCS outpatient 104 78 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 92.56 89 999999999 81.12 98.8 percent of total billed charges HETEROPHILE ANTIBODIES; SCREENING 3028630801_1 CDM 302 RC 86308 HCPCS outpatient 104 78 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 92.56 89 999999999 81.12 98.8 percent of total billed charges HETEROPHILE ANTIBODIES; SCREENING 3028630801_1 CDM 302 RC 86308 HCPCS outpatient 104 78 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 93.6 90 999999999 81.12 98.8 percent of total billed charges HETEROPHILE ANTIBODIES; SCREENING 3028630801_1 CDM 302 RC 86308 HCPCS outpatient 104 78 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 98.8 95 999999999 81.12 98.8 percent of total billed charges HETEROPHILE ANTIBODIES; SCREENING 3028630801_1 CDM 302 RC 86308 HCPCS outpatient 104 78 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 98.8 95 999999999 81.12 98.8 percent of total billed charges HETEROPHILE ANTIBODIES; SCREENING 3028630801_1 CDM 302 RC 86308 HCPCS outpatient 104 78 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 92.56 89 999999999 81.12 98.8 percent of total billed charges HETEROPHILE ANTIBODIES; SCREENING 3028630801_1 CDM 302 RC 86308 HCPCS outpatient 104 78 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 91.52 88 999999999 81.12 98.8 percent of total billed charges HETEROPHILE ANTIBODIES; SCREENING 3028630801_1 CDM 302 RC 86308 HCPCS outpatient 104 78 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 92.56 89 999999999 81.12 98.8 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, OTHER ANTIGEN, QUANTITATIVE (EG, CA 50, 72-4, 549), EACH" 3028631601_1 CDM 302 RC 86316 HCPCS outpatient 156 117 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 140.4 90 999999999 121.68 148.2 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, OTHER ANTIGEN, QUANTITATIVE (EG, CA 50, 72-4, 549), EACH" 3028631601_1 CDM 302 RC 86316 HCPCS outpatient 156 117 AETNA MCR ADV AETNA MCR ADV 121.68 78 999999999 121.68 148.2 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, OTHER ANTIGEN, QUANTITATIVE (EG, CA 50, 72-4, 549), EACH" 3028631601_1 CDM 302 RC 86316 HCPCS outpatient 156 117 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 136.61 87.57 999999999 121.68 148.2 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, OTHER ANTIGEN, QUANTITATIVE (EG, CA 50, 72-4, 549), EACH" 3028631601_1 CDM 302 RC 86316 HCPCS outpatient 156 117 COORDINATED CARE MCAID COORDINATED CARE MCAID 132.71 85.07 999999999 121.68 148.2 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, OTHER ANTIGEN, QUANTITATIVE (EG, CA 50, 72-4, 549), EACH" 3028631601_1 CDM 302 RC 86316 HCPCS outpatient 156 117 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 132.71 85.07 999999999 121.68 148.2 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, OTHER ANTIGEN, QUANTITATIVE (EG, CA 50, 72-4, 549), EACH" 3028631601_1 CDM 302 RC 86316 HCPCS outpatient 156 117 MOLINA MCAID MOLINA MCAID 130.1 83.4 999999999 121.68 148.2 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, OTHER ANTIGEN, QUANTITATIVE (EG, CA 50, 72-4, 549), EACH" 3028631601_1 CDM 302 RC 86316 HCPCS outpatient 156 117 MOLINA MCR ADV MOLINA MCR ADV 138.84 89 999999999 121.68 148.2 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, OTHER ANTIGEN, QUANTITATIVE (EG, CA 50, 72-4, 549), EACH" 3028631601_1 CDM 302 RC 86316 HCPCS outpatient 156 117 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 138.84 89 999999999 121.68 148.2 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, OTHER ANTIGEN, QUANTITATIVE (EG, CA 50, 72-4, 549), EACH" 3028631601_1 CDM 302 RC 86316 HCPCS outpatient 156 117 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 138.84 89 999999999 121.68 148.2 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, OTHER ANTIGEN, QUANTITATIVE (EG, CA 50, 72-4, 549), EACH" 3028631601_1 CDM 302 RC 86316 HCPCS outpatient 156 117 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 140.4 90 999999999 121.68 148.2 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, OTHER ANTIGEN, QUANTITATIVE (EG, CA 50, 72-4, 549), EACH" 3028631601_1 CDM 302 RC 86316 HCPCS outpatient 156 117 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 148.2 95 999999999 121.68 148.2 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, OTHER ANTIGEN, QUANTITATIVE (EG, CA 50, 72-4, 549), EACH" 3028631601_1 CDM 302 RC 86316 HCPCS outpatient 156 117 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 148.2 95 999999999 121.68 148.2 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, OTHER ANTIGEN, QUANTITATIVE (EG, CA 50, 72-4, 549), EACH" 3028631601_1 CDM 302 RC 86316 HCPCS outpatient 156 117 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 138.84 89 999999999 121.68 148.2 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, OTHER ANTIGEN, QUANTITATIVE (EG, CA 50, 72-4, 549), EACH" 3028631601_1 CDM 302 RC 86316 HCPCS outpatient 156 117 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 137.28 88 999999999 121.68 148.2 percent of total billed charges "IMMUNOASSAY FOR TUMOR ANTIGEN, OTHER ANTIGEN, QUANTITATIVE (EG, CA 50, 72-4, 549), EACH" 3028631601_1 CDM 302 RC 86316 HCPCS outpatient 156 117 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 138.84 89 999999999 121.68 148.2 percent of total billed charges IMMUNOFIXATION ELECTROPHORESIS; SERUM 3028633401_1 CDM 302 RC 86334 HCPCS outpatient 163 122.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 146.7 90 999999999 127.14 154.85 percent of total billed charges IMMUNOFIXATION ELECTROPHORESIS; SERUM 3028633401_1 CDM 302 RC 86334 HCPCS outpatient 163 122.25 AETNA MCR ADV AETNA MCR ADV 127.14 78 999999999 127.14 154.85 percent of total billed charges IMMUNOFIXATION ELECTROPHORESIS; SERUM 3028633401_1 CDM 302 RC 86334 HCPCS outpatient 163 122.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 142.74 87.57 999999999 127.14 154.85 percent of total billed charges IMMUNOFIXATION ELECTROPHORESIS; SERUM 3028633401_1 CDM 302 RC 86334 HCPCS outpatient 163 122.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 138.66 85.07 999999999 127.14 154.85 percent of total billed charges IMMUNOFIXATION ELECTROPHORESIS; SERUM 3028633401_1 CDM 302 RC 86334 HCPCS outpatient 163 122.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 138.66 85.07 999999999 127.14 154.85 percent of total billed charges IMMUNOFIXATION ELECTROPHORESIS; SERUM 3028633401_1 CDM 302 RC 86334 HCPCS outpatient 163 122.25 MOLINA MCAID MOLINA MCAID 135.94 83.4 999999999 127.14 154.85 percent of total billed charges IMMUNOFIXATION ELECTROPHORESIS; SERUM 3028633401_1 CDM 302 RC 86334 HCPCS outpatient 163 122.25 MOLINA MCR ADV MOLINA MCR ADV 145.07 89 999999999 127.14 154.85 percent of total billed charges IMMUNOFIXATION ELECTROPHORESIS; SERUM 3028633401_1 CDM 302 RC 86334 HCPCS outpatient 163 122.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 145.07 89 999999999 127.14 154.85 percent of total billed charges IMMUNOFIXATION ELECTROPHORESIS; SERUM 3028633401_1 CDM 302 RC 86334 HCPCS outpatient 163 122.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 145.07 89 999999999 127.14 154.85 percent of total billed charges IMMUNOFIXATION ELECTROPHORESIS; SERUM 3028633401_1 CDM 302 RC 86334 HCPCS outpatient 163 122.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 146.7 90 999999999 127.14 154.85 percent of total billed charges IMMUNOFIXATION ELECTROPHORESIS; SERUM 3028633401_1 CDM 302 RC 86334 HCPCS outpatient 163 122.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 154.85 95 999999999 127.14 154.85 percent of total billed charges IMMUNOFIXATION ELECTROPHORESIS; SERUM 3028633401_1 CDM 302 RC 86334 HCPCS outpatient 163 122.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 154.85 95 999999999 127.14 154.85 percent of total billed charges IMMUNOFIXATION ELECTROPHORESIS; SERUM 3028633401_1 CDM 302 RC 86334 HCPCS outpatient 163 122.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 145.07 89 999999999 127.14 154.85 percent of total billed charges IMMUNOFIXATION ELECTROPHORESIS; SERUM 3028633401_1 CDM 302 RC 86334 HCPCS outpatient 163 122.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 143.44 88 999999999 127.14 154.85 percent of total billed charges IMMUNOFIXATION ELECTROPHORESIS; SERUM 3028633401_1 CDM 302 RC 86334 HCPCS outpatient 163 122.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 145.07 89 999999999 127.14 154.85 percent of total billed charges "T CELLS; ABSOLUTE CD4 AND CD8 COUNT, INCLUDING RATIO" 3028636003_1 CDM 302 RC 86360 HCPCS outpatient 114 85.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 102.6 90 999999999 88.92 108.3 percent of total billed charges "T CELLS; ABSOLUTE CD4 AND CD8 COUNT, INCLUDING RATIO" 3028636003_1 CDM 302 RC 86360 HCPCS outpatient 114 85.5 AETNA MCR ADV AETNA MCR ADV 88.92 78 999999999 88.92 108.3 percent of total billed charges "T CELLS; ABSOLUTE CD4 AND CD8 COUNT, INCLUDING RATIO" 3028636003_1 CDM 302 RC 86360 HCPCS outpatient 114 85.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 99.83 87.57 999999999 88.92 108.3 percent of total billed charges "T CELLS; ABSOLUTE CD4 AND CD8 COUNT, INCLUDING RATIO" 3028636003_1 CDM 302 RC 86360 HCPCS outpatient 114 85.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 96.98 85.07 999999999 88.92 108.3 percent of total billed charges "T CELLS; ABSOLUTE CD4 AND CD8 COUNT, INCLUDING RATIO" 3028636003_1 CDM 302 RC 86360 HCPCS outpatient 114 85.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 96.98 85.07 999999999 88.92 108.3 percent of total billed charges "T CELLS; ABSOLUTE CD4 AND CD8 COUNT, INCLUDING RATIO" 3028636003_1 CDM 302 RC 86360 HCPCS outpatient 114 85.5 MOLINA MCAID MOLINA MCAID 95.08 83.4 999999999 88.92 108.3 percent of total billed charges "T CELLS; ABSOLUTE CD4 AND CD8 COUNT, INCLUDING RATIO" 3028636003_1 CDM 302 RC 86360 HCPCS outpatient 114 85.5 MOLINA MCR ADV MOLINA MCR ADV 101.46 89 999999999 88.92 108.3 percent of total billed charges "T CELLS; ABSOLUTE CD4 AND CD8 COUNT, INCLUDING RATIO" 3028636003_1 CDM 302 RC 86360 HCPCS outpatient 114 85.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 101.46 89 999999999 88.92 108.3 percent of total billed charges "T CELLS; ABSOLUTE CD4 AND CD8 COUNT, INCLUDING RATIO" 3028636003_1 CDM 302 RC 86360 HCPCS outpatient 114 85.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 101.46 89 999999999 88.92 108.3 percent of total billed charges "T CELLS; ABSOLUTE CD4 AND CD8 COUNT, INCLUDING RATIO" 3028636003_1 CDM 302 RC 86360 HCPCS outpatient 114 85.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 102.6 90 999999999 88.92 108.3 percent of total billed charges "T CELLS; ABSOLUTE CD4 AND CD8 COUNT, INCLUDING RATIO" 3028636003_1 CDM 302 RC 86360 HCPCS outpatient 114 85.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 108.3 95 999999999 88.92 108.3 percent of total billed charges "T CELLS; ABSOLUTE CD4 AND CD8 COUNT, INCLUDING RATIO" 3028636003_1 CDM 302 RC 86360 HCPCS outpatient 114 85.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 108.3 95 999999999 88.92 108.3 percent of total billed charges "T CELLS; ABSOLUTE CD4 AND CD8 COUNT, INCLUDING RATIO" 3028636003_1 CDM 302 RC 86360 HCPCS outpatient 114 85.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 101.46 89 999999999 88.92 108.3 percent of total billed charges "T CELLS; ABSOLUTE CD4 AND CD8 COUNT, INCLUDING RATIO" 3028636003_1 CDM 302 RC 86360 HCPCS outpatient 114 85.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 100.32 88 999999999 88.92 108.3 percent of total billed charges "T CELLS; ABSOLUTE CD4 AND CD8 COUNT, INCLUDING RATIO" 3028636003_1 CDM 302 RC 86360 HCPCS outpatient 114 85.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 101.46 89 999999999 88.92 108.3 percent of total billed charges "MICROSOMAL ANTIBODIES (EG, THYROID OR LIVER-KIDNEY), EACH" 3028637604_1 CDM 302 RC 86376 HCPCS outpatient 144 108 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 129.6 90 999999999 112.32 136.8 percent of total billed charges "MICROSOMAL ANTIBODIES (EG, THYROID OR LIVER-KIDNEY), EACH" 3028637604_1 CDM 302 RC 86376 HCPCS outpatient 144 108 AETNA MCR ADV AETNA MCR ADV 112.32 78 999999999 112.32 136.8 percent of total billed charges "MICROSOMAL ANTIBODIES (EG, THYROID OR LIVER-KIDNEY), EACH" 3028637604_1 CDM 302 RC 86376 HCPCS outpatient 144 108 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 126.1 87.57 999999999 112.32 136.8 percent of total billed charges "MICROSOMAL ANTIBODIES (EG, THYROID OR LIVER-KIDNEY), EACH" 3028637604_1 CDM 302 RC 86376 HCPCS outpatient 144 108 COORDINATED CARE MCAID COORDINATED CARE MCAID 122.5 85.07 999999999 112.32 136.8 percent of total billed charges "MICROSOMAL ANTIBODIES (EG, THYROID OR LIVER-KIDNEY), EACH" 3028637604_1 CDM 302 RC 86376 HCPCS outpatient 144 108 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 122.5 85.07 999999999 112.32 136.8 percent of total billed charges "MICROSOMAL ANTIBODIES (EG, THYROID OR LIVER-KIDNEY), EACH" 3028637604_1 CDM 302 RC 86376 HCPCS outpatient 144 108 MOLINA MCAID MOLINA MCAID 120.1 83.4 999999999 112.32 136.8 percent of total billed charges "MICROSOMAL ANTIBODIES (EG, THYROID OR LIVER-KIDNEY), EACH" 3028637604_1 CDM 302 RC 86376 HCPCS outpatient 144 108 MOLINA MCR ADV MOLINA MCR ADV 128.16 89 999999999 112.32 136.8 percent of total billed charges "MICROSOMAL ANTIBODIES (EG, THYROID OR LIVER-KIDNEY), EACH" 3028637604_1 CDM 302 RC 86376 HCPCS outpatient 144 108 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 128.16 89 999999999 112.32 136.8 percent of total billed charges "MICROSOMAL ANTIBODIES (EG, THYROID OR LIVER-KIDNEY), EACH" 3028637604_1 CDM 302 RC 86376 HCPCS outpatient 144 108 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 128.16 89 999999999 112.32 136.8 percent of total billed charges "MICROSOMAL ANTIBODIES (EG, THYROID OR LIVER-KIDNEY), EACH" 3028637604_1 CDM 302 RC 86376 HCPCS outpatient 144 108 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 129.6 90 999999999 112.32 136.8 percent of total billed charges "MICROSOMAL ANTIBODIES (EG, THYROID OR LIVER-KIDNEY), EACH" 3028637604_1 CDM 302 RC 86376 HCPCS outpatient 144 108 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 136.8 95 999999999 112.32 136.8 percent of total billed charges "MICROSOMAL ANTIBODIES (EG, THYROID OR LIVER-KIDNEY), EACH" 3028637604_1 CDM 302 RC 86376 HCPCS outpatient 144 108 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 136.8 95 999999999 112.32 136.8 percent of total billed charges "MICROSOMAL ANTIBODIES (EG, THYROID OR LIVER-KIDNEY), EACH" 3028637604_1 CDM 302 RC 86376 HCPCS outpatient 144 108 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 128.16 89 999999999 112.32 136.8 percent of total billed charges "MICROSOMAL ANTIBODIES (EG, THYROID OR LIVER-KIDNEY), EACH" 3028637604_1 CDM 302 RC 86376 HCPCS outpatient 144 108 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 126.72 88 999999999 112.32 136.8 percent of total billed charges "MICROSOMAL ANTIBODIES (EG, THYROID OR LIVER-KIDNEY), EACH" 3028637604_1 CDM 302 RC 86376 HCPCS outpatient 144 108 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 128.16 89 999999999 112.32 136.8 percent of total billed charges RHEUMATOID FACTOR; QUANTITATIVE 3028643101_1 CDM 302 RC 86431 HCPCS outpatient 84 63 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 75.6 90 999999999 65.52 79.8 percent of total billed charges RHEUMATOID FACTOR; QUANTITATIVE 3028643101_1 CDM 302 RC 86431 HCPCS outpatient 84 63 AETNA MCR ADV AETNA MCR ADV 65.52 78 999999999 65.52 79.8 percent of total billed charges RHEUMATOID FACTOR; QUANTITATIVE 3028643101_1 CDM 302 RC 86431 HCPCS outpatient 84 63 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 73.56 87.57 999999999 65.52 79.8 percent of total billed charges RHEUMATOID FACTOR; QUANTITATIVE 3028643101_1 CDM 302 RC 86431 HCPCS outpatient 84 63 COORDINATED CARE MCAID COORDINATED CARE MCAID 71.46 85.07 999999999 65.52 79.8 percent of total billed charges RHEUMATOID FACTOR; QUANTITATIVE 3028643101_1 CDM 302 RC 86431 HCPCS outpatient 84 63 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 71.46 85.07 999999999 65.52 79.8 percent of total billed charges RHEUMATOID FACTOR; QUANTITATIVE 3028643101_1 CDM 302 RC 86431 HCPCS outpatient 84 63 MOLINA MCAID MOLINA MCAID 70.06 83.4 999999999 65.52 79.8 percent of total billed charges RHEUMATOID FACTOR; QUANTITATIVE 3028643101_1 CDM 302 RC 86431 HCPCS outpatient 84 63 MOLINA MCR ADV MOLINA MCR ADV 74.76 89 999999999 65.52 79.8 percent of total billed charges RHEUMATOID FACTOR; QUANTITATIVE 3028643101_1 CDM 302 RC 86431 HCPCS outpatient 84 63 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 74.76 89 999999999 65.52 79.8 percent of total billed charges RHEUMATOID FACTOR; QUANTITATIVE 3028643101_1 CDM 302 RC 86431 HCPCS outpatient 84 63 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 74.76 89 999999999 65.52 79.8 percent of total billed charges RHEUMATOID FACTOR; QUANTITATIVE 3028643101_1 CDM 302 RC 86431 HCPCS outpatient 84 63 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 75.6 90 999999999 65.52 79.8 percent of total billed charges RHEUMATOID FACTOR; QUANTITATIVE 3028643101_1 CDM 302 RC 86431 HCPCS outpatient 84 63 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 79.8 95 999999999 65.52 79.8 percent of total billed charges RHEUMATOID FACTOR; QUANTITATIVE 3028643101_1 CDM 302 RC 86431 HCPCS outpatient 84 63 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 79.8 95 999999999 65.52 79.8 percent of total billed charges RHEUMATOID FACTOR; QUANTITATIVE 3028643101_1 CDM 302 RC 86431 HCPCS outpatient 84 63 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 74.76 89 999999999 65.52 79.8 percent of total billed charges RHEUMATOID FACTOR; QUANTITATIVE 3028643101_1 CDM 302 RC 86431 HCPCS outpatient 84 63 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 73.92 88 999999999 65.52 79.8 percent of total billed charges RHEUMATOID FACTOR; QUANTITATIVE 3028643101_1 CDM 302 RC 86431 HCPCS outpatient 84 63 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 74.76 89 999999999 65.52 79.8 percent of total billed charges "TUBERCULOSIS TEST, CELL MEDIATED IMMUNITY ANTIGEN RESPONSE MEASUREMENT; ENUMERATION OF GAMMA INTERFERON-PRODUCING T-CELLS IN CELL SUSPENSION" 3028648101_1 CDM 302 RC 86481 HCPCS outpatient 253 189.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 227.7 90 999999999 197.34 240.35 percent of total billed charges "TUBERCULOSIS TEST, CELL MEDIATED IMMUNITY ANTIGEN RESPONSE MEASUREMENT; ENUMERATION OF GAMMA INTERFERON-PRODUCING T-CELLS IN CELL SUSPENSION" 3028648101_1 CDM 302 RC 86481 HCPCS outpatient 253 189.75 AETNA MCR ADV AETNA MCR ADV 197.34 78 999999999 197.34 240.35 percent of total billed charges "TUBERCULOSIS TEST, CELL MEDIATED IMMUNITY ANTIGEN RESPONSE MEASUREMENT; ENUMERATION OF GAMMA INTERFERON-PRODUCING T-CELLS IN CELL SUSPENSION" 3028648101_1 CDM 302 RC 86481 HCPCS outpatient 253 189.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 221.55 87.57 999999999 197.34 240.35 percent of total billed charges "TUBERCULOSIS TEST, CELL MEDIATED IMMUNITY ANTIGEN RESPONSE MEASUREMENT; ENUMERATION OF GAMMA INTERFERON-PRODUCING T-CELLS IN CELL SUSPENSION" 3028648101_1 CDM 302 RC 86481 HCPCS outpatient 253 189.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 215.23 85.07 999999999 197.34 240.35 percent of total billed charges "TUBERCULOSIS TEST, CELL MEDIATED IMMUNITY ANTIGEN RESPONSE MEASUREMENT; ENUMERATION OF GAMMA INTERFERON-PRODUCING T-CELLS IN CELL SUSPENSION" 3028648101_1 CDM 302 RC 86481 HCPCS outpatient 253 189.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 215.23 85.07 999999999 197.34 240.35 percent of total billed charges "TUBERCULOSIS TEST, CELL MEDIATED IMMUNITY ANTIGEN RESPONSE MEASUREMENT; ENUMERATION OF GAMMA INTERFERON-PRODUCING T-CELLS IN CELL SUSPENSION" 3028648101_1 CDM 302 RC 86481 HCPCS outpatient 253 189.75 MOLINA MCAID MOLINA MCAID 211 83.4 999999999 197.34 240.35 percent of total billed charges "TUBERCULOSIS TEST, CELL MEDIATED IMMUNITY ANTIGEN RESPONSE MEASUREMENT; ENUMERATION OF GAMMA INTERFERON-PRODUCING T-CELLS IN CELL SUSPENSION" 3028648101_1 CDM 302 RC 86481 HCPCS outpatient 253 189.75 MOLINA MCR ADV MOLINA MCR ADV 225.17 89 999999999 197.34 240.35 percent of total billed charges "TUBERCULOSIS TEST, CELL MEDIATED IMMUNITY ANTIGEN RESPONSE MEASUREMENT; ENUMERATION OF GAMMA INTERFERON-PRODUCING T-CELLS IN CELL SUSPENSION" 3028648101_1 CDM 302 RC 86481 HCPCS outpatient 253 189.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 225.17 89 999999999 197.34 240.35 percent of total billed charges "TUBERCULOSIS TEST, CELL MEDIATED IMMUNITY ANTIGEN RESPONSE MEASUREMENT; ENUMERATION OF GAMMA INTERFERON-PRODUCING T-CELLS IN CELL SUSPENSION" 3028648101_1 CDM 302 RC 86481 HCPCS outpatient 253 189.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 225.17 89 999999999 197.34 240.35 percent of total billed charges "TUBERCULOSIS TEST, CELL MEDIATED IMMUNITY ANTIGEN RESPONSE MEASUREMENT; ENUMERATION OF GAMMA INTERFERON-PRODUCING T-CELLS IN CELL SUSPENSION" 3028648101_1 CDM 302 RC 86481 HCPCS outpatient 253 189.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 227.7 90 999999999 197.34 240.35 percent of total billed charges "TUBERCULOSIS TEST, CELL MEDIATED IMMUNITY ANTIGEN RESPONSE MEASUREMENT; ENUMERATION OF GAMMA INTERFERON-PRODUCING T-CELLS IN CELL SUSPENSION" 3028648101_1 CDM 302 RC 86481 HCPCS outpatient 253 189.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 240.35 95 999999999 197.34 240.35 percent of total billed charges "TUBERCULOSIS TEST, CELL MEDIATED IMMUNITY ANTIGEN RESPONSE MEASUREMENT; ENUMERATION OF GAMMA INTERFERON-PRODUCING T-CELLS IN CELL SUSPENSION" 3028648101_1 CDM 302 RC 86481 HCPCS outpatient 253 189.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 240.35 95 999999999 197.34 240.35 percent of total billed charges "TUBERCULOSIS TEST, CELL MEDIATED IMMUNITY ANTIGEN RESPONSE MEASUREMENT; ENUMERATION OF GAMMA INTERFERON-PRODUCING T-CELLS IN CELL SUSPENSION" 3028648101_1 CDM 302 RC 86481 HCPCS outpatient 253 189.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 225.17 89 999999999 197.34 240.35 percent of total billed charges "TUBERCULOSIS TEST, CELL MEDIATED IMMUNITY ANTIGEN RESPONSE MEASUREMENT; ENUMERATION OF GAMMA INTERFERON-PRODUCING T-CELLS IN CELL SUSPENSION" 3028648101_1 CDM 302 RC 86481 HCPCS outpatient 253 189.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 222.64 88 999999999 197.34 240.35 percent of total billed charges "TUBERCULOSIS TEST, CELL MEDIATED IMMUNITY ANTIGEN RESPONSE MEASUREMENT; ENUMERATION OF GAMMA INTERFERON-PRODUCING T-CELLS IN CELL SUSPENSION" 3028648101_1 CDM 302 RC 86481 HCPCS outpatient 253 189.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 225.17 89 999999999 197.34 240.35 percent of total billed charges "SKIN TEST; TUBERCULOSIS, INTRADERMAL" 3028658001_1 CDM 302 RC 86580 HCPCS outpatient 36 27 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 32.4 90 999999999 28.08 34.2 percent of total billed charges "SKIN TEST; TUBERCULOSIS, INTRADERMAL" 3028658001_1 CDM 302 RC 86580 HCPCS outpatient 36 27 AETNA MCR ADV AETNA MCR ADV 28.08 78 999999999 28.08 34.2 percent of total billed charges "SKIN TEST; TUBERCULOSIS, INTRADERMAL" 3028658001_1 CDM 302 RC 86580 HCPCS outpatient 36 27 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 31.53 87.57 999999999 28.08 34.2 percent of total billed charges "SKIN TEST; TUBERCULOSIS, INTRADERMAL" 3028658001_1 CDM 302 RC 86580 HCPCS outpatient 36 27 COORDINATED CARE MCAID COORDINATED CARE MCAID 30.63 85.07 999999999 28.08 34.2 percent of total billed charges "SKIN TEST; TUBERCULOSIS, INTRADERMAL" 3028658001_1 CDM 302 RC 86580 HCPCS outpatient 36 27 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 30.63 85.07 999999999 28.08 34.2 percent of total billed charges "SKIN TEST; TUBERCULOSIS, INTRADERMAL" 3028658001_1 CDM 302 RC 86580 HCPCS outpatient 36 27 MOLINA MCAID MOLINA MCAID 30.02 83.4 999999999 28.08 34.2 percent of total billed charges "SKIN TEST; TUBERCULOSIS, INTRADERMAL" 3028658001_1 CDM 302 RC 86580 HCPCS outpatient 36 27 MOLINA MCR ADV MOLINA MCR ADV 32.04 89 999999999 28.08 34.2 percent of total billed charges "SKIN TEST; TUBERCULOSIS, INTRADERMAL" 3028658001_1 CDM 302 RC 86580 HCPCS outpatient 36 27 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 32.04 89 999999999 28.08 34.2 percent of total billed charges "SKIN TEST; TUBERCULOSIS, INTRADERMAL" 3028658001_1 CDM 302 RC 86580 HCPCS outpatient 36 27 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 32.04 89 999999999 28.08 34.2 percent of total billed charges "SKIN TEST; TUBERCULOSIS, INTRADERMAL" 3028658001_1 CDM 302 RC 86580 HCPCS outpatient 36 27 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 32.4 90 999999999 28.08 34.2 percent of total billed charges "SKIN TEST; TUBERCULOSIS, INTRADERMAL" 3028658001_1 CDM 302 RC 86580 HCPCS outpatient 36 27 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 34.2 95 999999999 28.08 34.2 percent of total billed charges "SKIN TEST; TUBERCULOSIS, INTRADERMAL" 3028658001_1 CDM 302 RC 86580 HCPCS outpatient 36 27 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 34.2 95 999999999 28.08 34.2 percent of total billed charges "SKIN TEST; TUBERCULOSIS, INTRADERMAL" 3028658001_1 CDM 302 RC 86580 HCPCS outpatient 36 27 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 32.04 89 999999999 28.08 34.2 percent of total billed charges "SKIN TEST; TUBERCULOSIS, INTRADERMAL" 3028658001_1 CDM 302 RC 86580 HCPCS outpatient 36 27 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 31.68 88 999999999 28.08 34.2 percent of total billed charges "SKIN TEST; TUBERCULOSIS, INTRADERMAL" 3028658001_1 CDM 302 RC 86580 HCPCS outpatient 36 27 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 32.04 89 999999999 28.08 34.2 percent of total billed charges "SYPHILIS TEST, NON-TREPONEMAL ANTIBODY; QUALITATIVE (EG, VDRL, RPR, ART)" 3028659203_1 CDM 302 RC 86592 HCPCS outpatient 80 60 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 72 90 999999999 62.4 76 percent of total billed charges "SYPHILIS TEST, NON-TREPONEMAL ANTIBODY; QUALITATIVE (EG, VDRL, RPR, ART)" 3028659203_1 CDM 302 RC 86592 HCPCS outpatient 80 60 AETNA MCR ADV AETNA MCR ADV 62.4 78 999999999 62.4 76 percent of total billed charges "SYPHILIS TEST, NON-TREPONEMAL ANTIBODY; QUALITATIVE (EG, VDRL, RPR, ART)" 3028659203_1 CDM 302 RC 86592 HCPCS outpatient 80 60 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 70.06 87.57 999999999 62.4 76 percent of total billed charges "SYPHILIS TEST, NON-TREPONEMAL ANTIBODY; QUALITATIVE (EG, VDRL, RPR, ART)" 3028659203_1 CDM 302 RC 86592 HCPCS outpatient 80 60 COORDINATED CARE MCAID COORDINATED CARE MCAID 68.06 85.07 999999999 62.4 76 percent of total billed charges "SYPHILIS TEST, NON-TREPONEMAL ANTIBODY; QUALITATIVE (EG, VDRL, RPR, ART)" 3028659203_1 CDM 302 RC 86592 HCPCS outpatient 80 60 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 68.06 85.07 999999999 62.4 76 percent of total billed charges "SYPHILIS TEST, NON-TREPONEMAL ANTIBODY; QUALITATIVE (EG, VDRL, RPR, ART)" 3028659203_1 CDM 302 RC 86592 HCPCS outpatient 80 60 MOLINA MCAID MOLINA MCAID 66.72 83.4 999999999 62.4 76 percent of total billed charges "SYPHILIS TEST, NON-TREPONEMAL ANTIBODY; QUALITATIVE (EG, VDRL, RPR, ART)" 3028659203_1 CDM 302 RC 86592 HCPCS outpatient 80 60 MOLINA MCR ADV MOLINA MCR ADV 71.2 89 999999999 62.4 76 percent of total billed charges "SYPHILIS TEST, NON-TREPONEMAL ANTIBODY; QUALITATIVE (EG, VDRL, RPR, ART)" 3028659203_1 CDM 302 RC 86592 HCPCS outpatient 80 60 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 71.2 89 999999999 62.4 76 percent of total billed charges "SYPHILIS TEST, NON-TREPONEMAL ANTIBODY; QUALITATIVE (EG, VDRL, RPR, ART)" 3028659203_1 CDM 302 RC 86592 HCPCS outpatient 80 60 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 71.2 89 999999999 62.4 76 percent of total billed charges "SYPHILIS TEST, NON-TREPONEMAL ANTIBODY; QUALITATIVE (EG, VDRL, RPR, ART)" 3028659203_1 CDM 302 RC 86592 HCPCS outpatient 80 60 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 72 90 999999999 62.4 76 percent of total billed charges "SYPHILIS TEST, NON-TREPONEMAL ANTIBODY; QUALITATIVE (EG, VDRL, RPR, ART)" 3028659203_1 CDM 302 RC 86592 HCPCS outpatient 80 60 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 76 95 999999999 62.4 76 percent of total billed charges "SYPHILIS TEST, NON-TREPONEMAL ANTIBODY; QUALITATIVE (EG, VDRL, RPR, ART)" 3028659203_1 CDM 302 RC 86592 HCPCS outpatient 80 60 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 76 95 999999999 62.4 76 percent of total billed charges "SYPHILIS TEST, NON-TREPONEMAL ANTIBODY; QUALITATIVE (EG, VDRL, RPR, ART)" 3028659203_1 CDM 302 RC 86592 HCPCS outpatient 80 60 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 71.2 89 999999999 62.4 76 percent of total billed charges "SYPHILIS TEST, NON-TREPONEMAL ANTIBODY; QUALITATIVE (EG, VDRL, RPR, ART)" 3028659203_1 CDM 302 RC 86592 HCPCS outpatient 80 60 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 70.4 88 999999999 62.4 76 percent of total billed charges "SYPHILIS TEST, NON-TREPONEMAL ANTIBODY; QUALITATIVE (EG, VDRL, RPR, ART)" 3028659203_1 CDM 302 RC 86592 HCPCS outpatient 80 60 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 71.2 89 999999999 62.4 76 percent of total billed charges ANTIBODY; CANDIDA 3028662801_1 CDM 302 RC 86628 HCPCS outpatient 127 95.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 114.3 90 999999999 99.06 120.65 percent of total billed charges ANTIBODY; CANDIDA 3028662801_1 CDM 302 RC 86628 HCPCS outpatient 127 95.25 AETNA MCR ADV AETNA MCR ADV 99.06 78 999999999 99.06 120.65 percent of total billed charges ANTIBODY; CANDIDA 3028662801_1 CDM 302 RC 86628 HCPCS outpatient 127 95.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 111.21 87.57 999999999 99.06 120.65 percent of total billed charges ANTIBODY; CANDIDA 3028662801_1 CDM 302 RC 86628 HCPCS outpatient 127 95.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 108.04 85.07 999999999 99.06 120.65 percent of total billed charges ANTIBODY; CANDIDA 3028662801_1 CDM 302 RC 86628 HCPCS outpatient 127 95.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 108.04 85.07 999999999 99.06 120.65 percent of total billed charges ANTIBODY; CANDIDA 3028662801_1 CDM 302 RC 86628 HCPCS outpatient 127 95.25 MOLINA MCAID MOLINA MCAID 105.92 83.4 999999999 99.06 120.65 percent of total billed charges ANTIBODY; CANDIDA 3028662801_1 CDM 302 RC 86628 HCPCS outpatient 127 95.25 MOLINA MCR ADV MOLINA MCR ADV 113.03 89 999999999 99.06 120.65 percent of total billed charges ANTIBODY; CANDIDA 3028662801_1 CDM 302 RC 86628 HCPCS outpatient 127 95.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 113.03 89 999999999 99.06 120.65 percent of total billed charges ANTIBODY; CANDIDA 3028662801_1 CDM 302 RC 86628 HCPCS outpatient 127 95.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 113.03 89 999999999 99.06 120.65 percent of total billed charges ANTIBODY; CANDIDA 3028662801_1 CDM 302 RC 86628 HCPCS outpatient 127 95.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 114.3 90 999999999 99.06 120.65 percent of total billed charges ANTIBODY; CANDIDA 3028662801_1 CDM 302 RC 86628 HCPCS outpatient 127 95.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 120.65 95 999999999 99.06 120.65 percent of total billed charges ANTIBODY; CANDIDA 3028662801_1 CDM 302 RC 86628 HCPCS outpatient 127 95.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 120.65 95 999999999 99.06 120.65 percent of total billed charges ANTIBODY; CANDIDA 3028662801_1 CDM 302 RC 86628 HCPCS outpatient 127 95.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 113.03 89 999999999 99.06 120.65 percent of total billed charges ANTIBODY; CANDIDA 3028662801_1 CDM 302 RC 86628 HCPCS outpatient 127 95.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 111.76 88 999999999 99.06 120.65 percent of total billed charges ANTIBODY; CANDIDA 3028662801_1 CDM 302 RC 86628 HCPCS outpatient 127 95.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 113.03 89 999999999 99.06 120.65 percent of total billed charges ANTIBODY; CYTOMEGALOVIRUS (CMV) 3028664402_1 CDM 302 RC 86644 HCPCS outpatient 202 151.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 181.8 90 999999999 157.56 191.9 percent of total billed charges ANTIBODY; CYTOMEGALOVIRUS (CMV) 3028664402_1 CDM 302 RC 86644 HCPCS outpatient 202 151.5 AETNA MCR ADV AETNA MCR ADV 157.56 78 999999999 157.56 191.9 percent of total billed charges ANTIBODY; CYTOMEGALOVIRUS (CMV) 3028664402_1 CDM 302 RC 86644 HCPCS outpatient 202 151.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 176.89 87.57 999999999 157.56 191.9 percent of total billed charges ANTIBODY; CYTOMEGALOVIRUS (CMV) 3028664402_1 CDM 302 RC 86644 HCPCS outpatient 202 151.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 171.84 85.07 999999999 157.56 191.9 percent of total billed charges ANTIBODY; CYTOMEGALOVIRUS (CMV) 3028664402_1 CDM 302 RC 86644 HCPCS outpatient 202 151.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 171.84 85.07 999999999 157.56 191.9 percent of total billed charges ANTIBODY; CYTOMEGALOVIRUS (CMV) 3028664402_1 CDM 302 RC 86644 HCPCS outpatient 202 151.5 MOLINA MCAID MOLINA MCAID 168.47 83.4 999999999 157.56 191.9 percent of total billed charges ANTIBODY; CYTOMEGALOVIRUS (CMV) 3028664402_1 CDM 302 RC 86644 HCPCS outpatient 202 151.5 MOLINA MCR ADV MOLINA MCR ADV 179.78 89 999999999 157.56 191.9 percent of total billed charges ANTIBODY; CYTOMEGALOVIRUS (CMV) 3028664402_1 CDM 302 RC 86644 HCPCS outpatient 202 151.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 179.78 89 999999999 157.56 191.9 percent of total billed charges ANTIBODY; CYTOMEGALOVIRUS (CMV) 3028664402_1 CDM 302 RC 86644 HCPCS outpatient 202 151.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 179.78 89 999999999 157.56 191.9 percent of total billed charges ANTIBODY; CYTOMEGALOVIRUS (CMV) 3028664402_1 CDM 302 RC 86644 HCPCS outpatient 202 151.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 181.8 90 999999999 157.56 191.9 percent of total billed charges ANTIBODY; CYTOMEGALOVIRUS (CMV) 3028664402_1 CDM 302 RC 86644 HCPCS outpatient 202 151.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 191.9 95 999999999 157.56 191.9 percent of total billed charges ANTIBODY; CYTOMEGALOVIRUS (CMV) 3028664402_1 CDM 302 RC 86644 HCPCS outpatient 202 151.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 191.9 95 999999999 157.56 191.9 percent of total billed charges ANTIBODY; CYTOMEGALOVIRUS (CMV) 3028664402_1 CDM 302 RC 86644 HCPCS outpatient 202 151.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 179.78 89 999999999 157.56 191.9 percent of total billed charges ANTIBODY; CYTOMEGALOVIRUS (CMV) 3028664402_1 CDM 302 RC 86644 HCPCS outpatient 202 151.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 177.76 88 999999999 157.56 191.9 percent of total billed charges ANTIBODY; CYTOMEGALOVIRUS (CMV) 3028664402_1 CDM 302 RC 86644 HCPCS outpatient 202 151.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 179.78 89 999999999 157.56 191.9 percent of total billed charges "ANTIBODY; CYTOMEGALOVIRUS (CMV), IGM" 3028664501_1 CDM 302 RC 86645 HCPCS outpatient 180 135 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 162 90 999999999 140.4 171 percent of total billed charges "ANTIBODY; CYTOMEGALOVIRUS (CMV), IGM" 3028664501_1 CDM 302 RC 86645 HCPCS outpatient 180 135 AETNA MCR ADV AETNA MCR ADV 140.4 78 999999999 140.4 171 percent of total billed charges "ANTIBODY; CYTOMEGALOVIRUS (CMV), IGM" 3028664501_1 CDM 302 RC 86645 HCPCS outpatient 180 135 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 157.63 87.57 999999999 140.4 171 percent of total billed charges "ANTIBODY; CYTOMEGALOVIRUS (CMV), IGM" 3028664501_1 CDM 302 RC 86645 HCPCS outpatient 180 135 COORDINATED CARE MCAID COORDINATED CARE MCAID 153.13 85.07 999999999 140.4 171 percent of total billed charges "ANTIBODY; CYTOMEGALOVIRUS (CMV), IGM" 3028664501_1 CDM 302 RC 86645 HCPCS outpatient 180 135 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 153.13 85.07 999999999 140.4 171 percent of total billed charges "ANTIBODY; CYTOMEGALOVIRUS (CMV), IGM" 3028664501_1 CDM 302 RC 86645 HCPCS outpatient 180 135 MOLINA MCAID MOLINA MCAID 150.12 83.4 999999999 140.4 171 percent of total billed charges "ANTIBODY; CYTOMEGALOVIRUS (CMV), IGM" 3028664501_1 CDM 302 RC 86645 HCPCS outpatient 180 135 MOLINA MCR ADV MOLINA MCR ADV 160.2 89 999999999 140.4 171 percent of total billed charges "ANTIBODY; CYTOMEGALOVIRUS (CMV), IGM" 3028664501_1 CDM 302 RC 86645 HCPCS outpatient 180 135 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 160.2 89 999999999 140.4 171 percent of total billed charges "ANTIBODY; CYTOMEGALOVIRUS (CMV), IGM" 3028664501_1 CDM 302 RC 86645 HCPCS outpatient 180 135 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 160.2 89 999999999 140.4 171 percent of total billed charges "ANTIBODY; CYTOMEGALOVIRUS (CMV), IGM" 3028664501_1 CDM 302 RC 86645 HCPCS outpatient 180 135 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 162 90 999999999 140.4 171 percent of total billed charges "ANTIBODY; CYTOMEGALOVIRUS (CMV), IGM" 3028664501_1 CDM 302 RC 86645 HCPCS outpatient 180 135 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 171 95 999999999 140.4 171 percent of total billed charges "ANTIBODY; CYTOMEGALOVIRUS (CMV), IGM" 3028664501_1 CDM 302 RC 86645 HCPCS outpatient 180 135 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 171 95 999999999 140.4 171 percent of total billed charges "ANTIBODY; CYTOMEGALOVIRUS (CMV), IGM" 3028664501_1 CDM 302 RC 86645 HCPCS outpatient 180 135 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 160.2 89 999999999 140.4 171 percent of total billed charges "ANTIBODY; CYTOMEGALOVIRUS (CMV), IGM" 3028664501_1 CDM 302 RC 86645 HCPCS outpatient 180 135 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 158.4 88 999999999 140.4 171 percent of total billed charges "ANTIBODY; CYTOMEGALOVIRUS (CMV), IGM" 3028664501_1 CDM 302 RC 86645 HCPCS outpatient 180 135 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 160.2 89 999999999 140.4 171 percent of total billed charges "ANTIBODY; EPSTEIN-BARR (EB) VIRUS, NUCLEAR ANTIGEN (EBNA)" 3028666402_1 CDM 302 RC 86664 HCPCS outpatient 144 108 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 129.6 90 999999999 112.32 136.8 percent of total billed charges "ANTIBODY; EPSTEIN-BARR (EB) VIRUS, NUCLEAR ANTIGEN (EBNA)" 3028666402_1 CDM 302 RC 86664 HCPCS outpatient 144 108 AETNA MCR ADV AETNA MCR ADV 112.32 78 999999999 112.32 136.8 percent of total billed charges "ANTIBODY; EPSTEIN-BARR (EB) VIRUS, NUCLEAR ANTIGEN (EBNA)" 3028666402_1 CDM 302 RC 86664 HCPCS outpatient 144 108 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 126.1 87.57 999999999 112.32 136.8 percent of total billed charges "ANTIBODY; EPSTEIN-BARR (EB) VIRUS, NUCLEAR ANTIGEN (EBNA)" 3028666402_1 CDM 302 RC 86664 HCPCS outpatient 144 108 COORDINATED CARE MCAID COORDINATED CARE MCAID 122.5 85.07 999999999 112.32 136.8 percent of total billed charges "ANTIBODY; EPSTEIN-BARR (EB) VIRUS, NUCLEAR ANTIGEN (EBNA)" 3028666402_1 CDM 302 RC 86664 HCPCS outpatient 144 108 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 122.5 85.07 999999999 112.32 136.8 percent of total billed charges "ANTIBODY; EPSTEIN-BARR (EB) VIRUS, NUCLEAR ANTIGEN (EBNA)" 3028666402_1 CDM 302 RC 86664 HCPCS outpatient 144 108 MOLINA MCAID MOLINA MCAID 120.1 83.4 999999999 112.32 136.8 percent of total billed charges "ANTIBODY; EPSTEIN-BARR (EB) VIRUS, NUCLEAR ANTIGEN (EBNA)" 3028666402_1 CDM 302 RC 86664 HCPCS outpatient 144 108 MOLINA MCR ADV MOLINA MCR ADV 128.16 89 999999999 112.32 136.8 percent of total billed charges "ANTIBODY; EPSTEIN-BARR (EB) VIRUS, NUCLEAR ANTIGEN (EBNA)" 3028666402_1 CDM 302 RC 86664 HCPCS outpatient 144 108 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 128.16 89 999999999 112.32 136.8 percent of total billed charges "ANTIBODY; EPSTEIN-BARR (EB) VIRUS, NUCLEAR ANTIGEN (EBNA)" 3028666402_1 CDM 302 RC 86664 HCPCS outpatient 144 108 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 128.16 89 999999999 112.32 136.8 percent of total billed charges "ANTIBODY; EPSTEIN-BARR (EB) VIRUS, NUCLEAR ANTIGEN (EBNA)" 3028666402_1 CDM 302 RC 86664 HCPCS outpatient 144 108 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 129.6 90 999999999 112.32 136.8 percent of total billed charges "ANTIBODY; EPSTEIN-BARR (EB) VIRUS, NUCLEAR ANTIGEN (EBNA)" 3028666402_1 CDM 302 RC 86664 HCPCS outpatient 144 108 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 136.8 95 999999999 112.32 136.8 percent of total billed charges "ANTIBODY; EPSTEIN-BARR (EB) VIRUS, NUCLEAR ANTIGEN (EBNA)" 3028666402_1 CDM 302 RC 86664 HCPCS outpatient 144 108 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 136.8 95 999999999 112.32 136.8 percent of total billed charges "ANTIBODY; EPSTEIN-BARR (EB) VIRUS, NUCLEAR ANTIGEN (EBNA)" 3028666402_1 CDM 302 RC 86664 HCPCS outpatient 144 108 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 128.16 89 999999999 112.32 136.8 percent of total billed charges "ANTIBODY; EPSTEIN-BARR (EB) VIRUS, NUCLEAR ANTIGEN (EBNA)" 3028666402_1 CDM 302 RC 86664 HCPCS outpatient 144 108 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 126.72 88 999999999 112.32 136.8 percent of total billed charges "ANTIBODY; EPSTEIN-BARR (EB) VIRUS, NUCLEAR ANTIGEN (EBNA)" 3028666402_1 CDM 302 RC 86664 HCPCS outpatient 144 108 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 128.16 89 999999999 112.32 136.8 percent of total billed charges "ANTIBODY; EPSTEIN-BARR (EB) VIRUS, VIRAL CAPSID (VCA)" 3028666504_1 CDM 302 RC 86665 HCPCS outpatient 148 111 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 133.2 90 999999999 115.44 140.6 percent of total billed charges "ANTIBODY; EPSTEIN-BARR (EB) VIRUS, VIRAL CAPSID (VCA)" 3028666504_1 CDM 302 RC 86665 HCPCS outpatient 148 111 AETNA MCR ADV AETNA MCR ADV 115.44 78 999999999 115.44 140.6 percent of total billed charges "ANTIBODY; EPSTEIN-BARR (EB) VIRUS, VIRAL CAPSID (VCA)" 3028666504_1 CDM 302 RC 86665 HCPCS outpatient 148 111 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 129.6 87.57 999999999 115.44 140.6 percent of total billed charges "ANTIBODY; EPSTEIN-BARR (EB) VIRUS, VIRAL CAPSID (VCA)" 3028666504_1 CDM 302 RC 86665 HCPCS outpatient 148 111 COORDINATED CARE MCAID COORDINATED CARE MCAID 125.9 85.07 999999999 115.44 140.6 percent of total billed charges "ANTIBODY; EPSTEIN-BARR (EB) VIRUS, VIRAL CAPSID (VCA)" 3028666504_1 CDM 302 RC 86665 HCPCS outpatient 148 111 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 125.9 85.07 999999999 115.44 140.6 percent of total billed charges "ANTIBODY; EPSTEIN-BARR (EB) VIRUS, VIRAL CAPSID (VCA)" 3028666504_1 CDM 302 RC 86665 HCPCS outpatient 148 111 MOLINA MCAID MOLINA MCAID 123.43 83.4 999999999 115.44 140.6 percent of total billed charges "ANTIBODY; EPSTEIN-BARR (EB) VIRUS, VIRAL CAPSID (VCA)" 3028666504_1 CDM 302 RC 86665 HCPCS outpatient 148 111 MOLINA MCR ADV MOLINA MCR ADV 131.72 89 999999999 115.44 140.6 percent of total billed charges "ANTIBODY; EPSTEIN-BARR (EB) VIRUS, VIRAL CAPSID (VCA)" 3028666504_1 CDM 302 RC 86665 HCPCS outpatient 148 111 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 131.72 89 999999999 115.44 140.6 percent of total billed charges "ANTIBODY; EPSTEIN-BARR (EB) VIRUS, VIRAL CAPSID (VCA)" 3028666504_1 CDM 302 RC 86665 HCPCS outpatient 148 111 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 131.72 89 999999999 115.44 140.6 percent of total billed charges "ANTIBODY; EPSTEIN-BARR (EB) VIRUS, VIRAL CAPSID (VCA)" 3028666504_1 CDM 302 RC 86665 HCPCS outpatient 148 111 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 133.2 90 999999999 115.44 140.6 percent of total billed charges "ANTIBODY; EPSTEIN-BARR (EB) VIRUS, VIRAL CAPSID (VCA)" 3028666504_1 CDM 302 RC 86665 HCPCS outpatient 148 111 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 140.6 95 999999999 115.44 140.6 percent of total billed charges "ANTIBODY; EPSTEIN-BARR (EB) VIRUS, VIRAL CAPSID (VCA)" 3028666504_1 CDM 302 RC 86665 HCPCS outpatient 148 111 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 140.6 95 999999999 115.44 140.6 percent of total billed charges "ANTIBODY; EPSTEIN-BARR (EB) VIRUS, VIRAL CAPSID (VCA)" 3028666504_1 CDM 302 RC 86665 HCPCS outpatient 148 111 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 131.72 89 999999999 115.44 140.6 percent of total billed charges "ANTIBODY; EPSTEIN-BARR (EB) VIRUS, VIRAL CAPSID (VCA)" 3028666504_1 CDM 302 RC 86665 HCPCS outpatient 148 111 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 130.24 88 999999999 115.44 140.6 percent of total billed charges "ANTIBODY; EPSTEIN-BARR (EB) VIRUS, VIRAL CAPSID (VCA)" 3028666504_1 CDM 302 RC 86665 HCPCS outpatient 148 111 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 131.72 89 999999999 115.44 140.6 percent of total billed charges "ANTIBODY; HERPES SIMPLEX, TYPE 1" 3028669503_1 CDM 302 RC 86695 HCPCS outpatient 143 107.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 128.7 90 999999999 111.54 135.85 percent of total billed charges "ANTIBODY; HERPES SIMPLEX, TYPE 1" 3028669503_1 CDM 302 RC 86695 HCPCS outpatient 143 107.25 AETNA MCR ADV AETNA MCR ADV 111.54 78 999999999 111.54 135.85 percent of total billed charges "ANTIBODY; HERPES SIMPLEX, TYPE 1" 3028669503_1 CDM 302 RC 86695 HCPCS outpatient 143 107.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 125.23 87.57 999999999 111.54 135.85 percent of total billed charges "ANTIBODY; HERPES SIMPLEX, TYPE 1" 3028669503_1 CDM 302 RC 86695 HCPCS outpatient 143 107.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 121.65 85.07 999999999 111.54 135.85 percent of total billed charges "ANTIBODY; HERPES SIMPLEX, TYPE 1" 3028669503_1 CDM 302 RC 86695 HCPCS outpatient 143 107.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 121.65 85.07 999999999 111.54 135.85 percent of total billed charges "ANTIBODY; HERPES SIMPLEX, TYPE 1" 3028669503_1 CDM 302 RC 86695 HCPCS outpatient 143 107.25 MOLINA MCAID MOLINA MCAID 119.26 83.4 999999999 111.54 135.85 percent of total billed charges "ANTIBODY; HERPES SIMPLEX, TYPE 1" 3028669503_1 CDM 302 RC 86695 HCPCS outpatient 143 107.25 MOLINA MCR ADV MOLINA MCR ADV 127.27 89 999999999 111.54 135.85 percent of total billed charges "ANTIBODY; HERPES SIMPLEX, TYPE 1" 3028669503_1 CDM 302 RC 86695 HCPCS outpatient 143 107.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 127.27 89 999999999 111.54 135.85 percent of total billed charges "ANTIBODY; HERPES SIMPLEX, TYPE 1" 3028669503_1 CDM 302 RC 86695 HCPCS outpatient 143 107.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 127.27 89 999999999 111.54 135.85 percent of total billed charges "ANTIBODY; HERPES SIMPLEX, TYPE 1" 3028669503_1 CDM 302 RC 86695 HCPCS outpatient 143 107.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 128.7 90 999999999 111.54 135.85 percent of total billed charges "ANTIBODY; HERPES SIMPLEX, TYPE 1" 3028669503_1 CDM 302 RC 86695 HCPCS outpatient 143 107.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 135.85 95 999999999 111.54 135.85 percent of total billed charges "ANTIBODY; HERPES SIMPLEX, TYPE 1" 3028669503_1 CDM 302 RC 86695 HCPCS outpatient 143 107.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 135.85 95 999999999 111.54 135.85 percent of total billed charges "ANTIBODY; HERPES SIMPLEX, TYPE 1" 3028669503_1 CDM 302 RC 86695 HCPCS outpatient 143 107.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 127.27 89 999999999 111.54 135.85 percent of total billed charges "ANTIBODY; HERPES SIMPLEX, TYPE 1" 3028669503_1 CDM 302 RC 86695 HCPCS outpatient 143 107.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 125.84 88 999999999 111.54 135.85 percent of total billed charges "ANTIBODY; HERPES SIMPLEX, TYPE 1" 3028669503_1 CDM 302 RC 86695 HCPCS outpatient 143 107.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 127.27 89 999999999 111.54 135.85 percent of total billed charges "ANTIBODY; HERPES SIMPLEX, TYPE 2" 3028669603_1 CDM 302 RC 86696 HCPCS outpatient 202 151.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 181.8 90 999999999 157.56 191.9 percent of total billed charges "ANTIBODY; HERPES SIMPLEX, TYPE 2" 3028669603_1 CDM 302 RC 86696 HCPCS outpatient 202 151.5 AETNA MCR ADV AETNA MCR ADV 157.56 78 999999999 157.56 191.9 percent of total billed charges "ANTIBODY; HERPES SIMPLEX, TYPE 2" 3028669603_1 CDM 302 RC 86696 HCPCS outpatient 202 151.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 176.89 87.57 999999999 157.56 191.9 percent of total billed charges "ANTIBODY; HERPES SIMPLEX, TYPE 2" 3028669603_1 CDM 302 RC 86696 HCPCS outpatient 202 151.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 171.84 85.07 999999999 157.56 191.9 percent of total billed charges "ANTIBODY; HERPES SIMPLEX, TYPE 2" 3028669603_1 CDM 302 RC 86696 HCPCS outpatient 202 151.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 171.84 85.07 999999999 157.56 191.9 percent of total billed charges "ANTIBODY; HERPES SIMPLEX, TYPE 2" 3028669603_1 CDM 302 RC 86696 HCPCS outpatient 202 151.5 MOLINA MCAID MOLINA MCAID 168.47 83.4 999999999 157.56 191.9 percent of total billed charges "ANTIBODY; HERPES SIMPLEX, TYPE 2" 3028669603_1 CDM 302 RC 86696 HCPCS outpatient 202 151.5 MOLINA MCR ADV MOLINA MCR ADV 179.78 89 999999999 157.56 191.9 percent of total billed charges "ANTIBODY; HERPES SIMPLEX, TYPE 2" 3028669603_1 CDM 302 RC 86696 HCPCS outpatient 202 151.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 179.78 89 999999999 157.56 191.9 percent of total billed charges "ANTIBODY; HERPES SIMPLEX, TYPE 2" 3028669603_1 CDM 302 RC 86696 HCPCS outpatient 202 151.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 179.78 89 999999999 157.56 191.9 percent of total billed charges "ANTIBODY; HERPES SIMPLEX, TYPE 2" 3028669603_1 CDM 302 RC 86696 HCPCS outpatient 202 151.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 181.8 90 999999999 157.56 191.9 percent of total billed charges "ANTIBODY; HERPES SIMPLEX, TYPE 2" 3028669603_1 CDM 302 RC 86696 HCPCS outpatient 202 151.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 191.9 95 999999999 157.56 191.9 percent of total billed charges "ANTIBODY; HERPES SIMPLEX, TYPE 2" 3028669603_1 CDM 302 RC 86696 HCPCS outpatient 202 151.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 191.9 95 999999999 157.56 191.9 percent of total billed charges "ANTIBODY; HERPES SIMPLEX, TYPE 2" 3028669603_1 CDM 302 RC 86696 HCPCS outpatient 202 151.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 179.78 89 999999999 157.56 191.9 percent of total billed charges "ANTIBODY; HERPES SIMPLEX, TYPE 2" 3028669603_1 CDM 302 RC 86696 HCPCS outpatient 202 151.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 177.76 88 999999999 157.56 191.9 percent of total billed charges "ANTIBODY; HERPES SIMPLEX, TYPE 2" 3028669603_1 CDM 302 RC 86696 HCPCS outpatient 202 151.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 179.78 89 999999999 157.56 191.9 percent of total billed charges "ANTIBODY; HIV-1 AND HIV-2, SINGLE RESULT" 3028670301_1 CDM 302 RC 86703 HCPCS outpatient 125 93.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 112.5 90 999999999 97.5 118.75 percent of total billed charges "ANTIBODY; HIV-1 AND HIV-2, SINGLE RESULT" 3028670301_1 CDM 302 RC 86703 HCPCS outpatient 125 93.75 AETNA MCR ADV AETNA MCR ADV 97.5 78 999999999 97.5 118.75 percent of total billed charges "ANTIBODY; HIV-1 AND HIV-2, SINGLE RESULT" 3028670301_1 CDM 302 RC 86703 HCPCS outpatient 125 93.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 109.46 87.57 999999999 97.5 118.75 percent of total billed charges "ANTIBODY; HIV-1 AND HIV-2, SINGLE RESULT" 3028670301_1 CDM 302 RC 86703 HCPCS outpatient 125 93.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 106.34 85.07 999999999 97.5 118.75 percent of total billed charges "ANTIBODY; HIV-1 AND HIV-2, SINGLE RESULT" 3028670301_1 CDM 302 RC 86703 HCPCS outpatient 125 93.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 106.34 85.07 999999999 97.5 118.75 percent of total billed charges "ANTIBODY; HIV-1 AND HIV-2, SINGLE RESULT" 3028670301_1 CDM 302 RC 86703 HCPCS outpatient 125 93.75 MOLINA MCAID MOLINA MCAID 104.25 83.4 999999999 97.5 118.75 percent of total billed charges "ANTIBODY; HIV-1 AND HIV-2, SINGLE RESULT" 3028670301_1 CDM 302 RC 86703 HCPCS outpatient 125 93.75 MOLINA MCR ADV MOLINA MCR ADV 111.25 89 999999999 97.5 118.75 percent of total billed charges "ANTIBODY; HIV-1 AND HIV-2, SINGLE RESULT" 3028670301_1 CDM 302 RC 86703 HCPCS outpatient 125 93.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 111.25 89 999999999 97.5 118.75 percent of total billed charges "ANTIBODY; HIV-1 AND HIV-2, SINGLE RESULT" 3028670301_1 CDM 302 RC 86703 HCPCS outpatient 125 93.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 111.25 89 999999999 97.5 118.75 percent of total billed charges "ANTIBODY; HIV-1 AND HIV-2, SINGLE RESULT" 3028670301_1 CDM 302 RC 86703 HCPCS outpatient 125 93.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 112.5 90 999999999 97.5 118.75 percent of total billed charges "ANTIBODY; HIV-1 AND HIV-2, SINGLE RESULT" 3028670301_1 CDM 302 RC 86703 HCPCS outpatient 125 93.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 118.75 95 999999999 97.5 118.75 percent of total billed charges "ANTIBODY; HIV-1 AND HIV-2, SINGLE RESULT" 3028670301_1 CDM 302 RC 86703 HCPCS outpatient 125 93.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 118.75 95 999999999 97.5 118.75 percent of total billed charges "ANTIBODY; HIV-1 AND HIV-2, SINGLE RESULT" 3028670301_1 CDM 302 RC 86703 HCPCS outpatient 125 93.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 111.25 89 999999999 97.5 118.75 percent of total billed charges "ANTIBODY; HIV-1 AND HIV-2, SINGLE RESULT" 3028670301_1 CDM 302 RC 86703 HCPCS outpatient 125 93.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 110 88 999999999 97.5 118.75 percent of total billed charges "ANTIBODY; HIV-1 AND HIV-2, SINGLE RESULT" 3028670301_1 CDM 302 RC 86703 HCPCS outpatient 125 93.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 111.25 89 999999999 97.5 118.75 percent of total billed charges HEPATITIS B CORE ANTIBODY (HBCAB); TOTAL 3028670401_1 CDM 302 RC 86704 HCPCS outpatient 104 78 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 93.6 90 999999999 81.12 98.8 percent of total billed charges HEPATITIS B CORE ANTIBODY (HBCAB); TOTAL 3028670401_1 CDM 302 RC 86704 HCPCS outpatient 104 78 AETNA MCR ADV AETNA MCR ADV 81.12 78 999999999 81.12 98.8 percent of total billed charges HEPATITIS B CORE ANTIBODY (HBCAB); TOTAL 3028670401_1 CDM 302 RC 86704 HCPCS outpatient 104 78 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 91.07 87.57 999999999 81.12 98.8 percent of total billed charges HEPATITIS B CORE ANTIBODY (HBCAB); TOTAL 3028670401_1 CDM 302 RC 86704 HCPCS outpatient 104 78 COORDINATED CARE MCAID COORDINATED CARE MCAID 88.47 85.07 999999999 81.12 98.8 percent of total billed charges HEPATITIS B CORE ANTIBODY (HBCAB); TOTAL 3028670401_1 CDM 302 RC 86704 HCPCS outpatient 104 78 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 88.47 85.07 999999999 81.12 98.8 percent of total billed charges HEPATITIS B CORE ANTIBODY (HBCAB); TOTAL 3028670401_1 CDM 302 RC 86704 HCPCS outpatient 104 78 MOLINA MCAID MOLINA MCAID 86.74 83.4 999999999 81.12 98.8 percent of total billed charges HEPATITIS B CORE ANTIBODY (HBCAB); TOTAL 3028670401_1 CDM 302 RC 86704 HCPCS outpatient 104 78 MOLINA MCR ADV MOLINA MCR ADV 92.56 89 999999999 81.12 98.8 percent of total billed charges HEPATITIS B CORE ANTIBODY (HBCAB); TOTAL 3028670401_1 CDM 302 RC 86704 HCPCS outpatient 104 78 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 92.56 89 999999999 81.12 98.8 percent of total billed charges HEPATITIS B CORE ANTIBODY (HBCAB); TOTAL 3028670401_1 CDM 302 RC 86704 HCPCS outpatient 104 78 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 92.56 89 999999999 81.12 98.8 percent of total billed charges HEPATITIS B CORE ANTIBODY (HBCAB); TOTAL 3028670401_1 CDM 302 RC 86704 HCPCS outpatient 104 78 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 93.6 90 999999999 81.12 98.8 percent of total billed charges HEPATITIS B CORE ANTIBODY (HBCAB); TOTAL 3028670401_1 CDM 302 RC 86704 HCPCS outpatient 104 78 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 98.8 95 999999999 81.12 98.8 percent of total billed charges HEPATITIS B CORE ANTIBODY (HBCAB); TOTAL 3028670401_1 CDM 302 RC 86704 HCPCS outpatient 104 78 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 98.8 95 999999999 81.12 98.8 percent of total billed charges HEPATITIS B CORE ANTIBODY (HBCAB); TOTAL 3028670401_1 CDM 302 RC 86704 HCPCS outpatient 104 78 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 92.56 89 999999999 81.12 98.8 percent of total billed charges HEPATITIS B CORE ANTIBODY (HBCAB); TOTAL 3028670401_1 CDM 302 RC 86704 HCPCS outpatient 104 78 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 91.52 88 999999999 81.12 98.8 percent of total billed charges HEPATITIS B CORE ANTIBODY (HBCAB); TOTAL 3028670401_1 CDM 302 RC 86704 HCPCS outpatient 104 78 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 92.56 89 999999999 81.12 98.8 percent of total billed charges HEPATITIS B CORE ANTIBODY (HBCAB); IGM ANTIBODY 3028670501_1 CDM 302 RC 86705 HCPCS outpatient 260 195 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 234 90 999999999 202.8 247 percent of total billed charges HEPATITIS B CORE ANTIBODY (HBCAB); IGM ANTIBODY 3028670501_1 CDM 302 RC 86705 HCPCS outpatient 260 195 AETNA MCR ADV AETNA MCR ADV 202.8 78 999999999 202.8 247 percent of total billed charges HEPATITIS B CORE ANTIBODY (HBCAB); IGM ANTIBODY 3028670501_1 CDM 302 RC 86705 HCPCS outpatient 260 195 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 227.68 87.57 999999999 202.8 247 percent of total billed charges HEPATITIS B CORE ANTIBODY (HBCAB); IGM ANTIBODY 3028670501_1 CDM 302 RC 86705 HCPCS outpatient 260 195 COORDINATED CARE MCAID COORDINATED CARE MCAID 221.18 85.07 999999999 202.8 247 percent of total billed charges HEPATITIS B CORE ANTIBODY (HBCAB); IGM ANTIBODY 3028670501_1 CDM 302 RC 86705 HCPCS outpatient 260 195 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 221.18 85.07 999999999 202.8 247 percent of total billed charges HEPATITIS B CORE ANTIBODY (HBCAB); IGM ANTIBODY 3028670501_1 CDM 302 RC 86705 HCPCS outpatient 260 195 MOLINA MCAID MOLINA MCAID 216.84 83.4 999999999 202.8 247 percent of total billed charges HEPATITIS B CORE ANTIBODY (HBCAB); IGM ANTIBODY 3028670501_1 CDM 302 RC 86705 HCPCS outpatient 260 195 MOLINA MCR ADV MOLINA MCR ADV 231.4 89 999999999 202.8 247 percent of total billed charges HEPATITIS B CORE ANTIBODY (HBCAB); IGM ANTIBODY 3028670501_1 CDM 302 RC 86705 HCPCS outpatient 260 195 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 231.4 89 999999999 202.8 247 percent of total billed charges HEPATITIS B CORE ANTIBODY (HBCAB); IGM ANTIBODY 3028670501_1 CDM 302 RC 86705 HCPCS outpatient 260 195 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 231.4 89 999999999 202.8 247 percent of total billed charges HEPATITIS B CORE ANTIBODY (HBCAB); IGM ANTIBODY 3028670501_1 CDM 302 RC 86705 HCPCS outpatient 260 195 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 234 90 999999999 202.8 247 percent of total billed charges HEPATITIS B CORE ANTIBODY (HBCAB); IGM ANTIBODY 3028670501_1 CDM 302 RC 86705 HCPCS outpatient 260 195 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 247 95 999999999 202.8 247 percent of total billed charges HEPATITIS B CORE ANTIBODY (HBCAB); IGM ANTIBODY 3028670501_1 CDM 302 RC 86705 HCPCS outpatient 260 195 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 247 95 999999999 202.8 247 percent of total billed charges HEPATITIS B CORE ANTIBODY (HBCAB); IGM ANTIBODY 3028670501_1 CDM 302 RC 86705 HCPCS outpatient 260 195 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 231.4 89 999999999 202.8 247 percent of total billed charges HEPATITIS B CORE ANTIBODY (HBCAB); IGM ANTIBODY 3028670501_1 CDM 302 RC 86705 HCPCS outpatient 260 195 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 228.8 88 999999999 202.8 247 percent of total billed charges HEPATITIS B CORE ANTIBODY (HBCAB); IGM ANTIBODY 3028670501_1 CDM 302 RC 86705 HCPCS outpatient 260 195 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 231.4 89 999999999 202.8 247 percent of total billed charges HEPATITIS B SURFACE ANTIBODY (HBSAB) 3028670601_1 CDM 302 RC 86706 HCPCS outpatient 106 79.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 95.4 90 999999999 82.68 100.7 percent of total billed charges HEPATITIS B SURFACE ANTIBODY (HBSAB) 3028670601_1 CDM 302 RC 86706 HCPCS outpatient 106 79.5 AETNA MCR ADV AETNA MCR ADV 82.68 78 999999999 82.68 100.7 percent of total billed charges HEPATITIS B SURFACE ANTIBODY (HBSAB) 3028670601_1 CDM 302 RC 86706 HCPCS outpatient 106 79.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 92.82 87.57 999999999 82.68 100.7 percent of total billed charges HEPATITIS B SURFACE ANTIBODY (HBSAB) 3028670601_1 CDM 302 RC 86706 HCPCS outpatient 106 79.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 90.17 85.07 999999999 82.68 100.7 percent of total billed charges HEPATITIS B SURFACE ANTIBODY (HBSAB) 3028670601_1 CDM 302 RC 86706 HCPCS outpatient 106 79.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 90.17 85.07 999999999 82.68 100.7 percent of total billed charges HEPATITIS B SURFACE ANTIBODY (HBSAB) 3028670601_1 CDM 302 RC 86706 HCPCS outpatient 106 79.5 MOLINA MCAID MOLINA MCAID 88.4 83.4 999999999 82.68 100.7 percent of total billed charges HEPATITIS B SURFACE ANTIBODY (HBSAB) 3028670601_1 CDM 302 RC 86706 HCPCS outpatient 106 79.5 MOLINA MCR ADV MOLINA MCR ADV 94.34 89 999999999 82.68 100.7 percent of total billed charges HEPATITIS B SURFACE ANTIBODY (HBSAB) 3028670601_1 CDM 302 RC 86706 HCPCS outpatient 106 79.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 94.34 89 999999999 82.68 100.7 percent of total billed charges HEPATITIS B SURFACE ANTIBODY (HBSAB) 3028670601_1 CDM 302 RC 86706 HCPCS outpatient 106 79.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 94.34 89 999999999 82.68 100.7 percent of total billed charges HEPATITIS B SURFACE ANTIBODY (HBSAB) 3028670601_1 CDM 302 RC 86706 HCPCS outpatient 106 79.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 95.4 90 999999999 82.68 100.7 percent of total billed charges HEPATITIS B SURFACE ANTIBODY (HBSAB) 3028670601_1 CDM 302 RC 86706 HCPCS outpatient 106 79.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 100.7 95 999999999 82.68 100.7 percent of total billed charges HEPATITIS B SURFACE ANTIBODY (HBSAB) 3028670601_1 CDM 302 RC 86706 HCPCS outpatient 106 79.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 100.7 95 999999999 82.68 100.7 percent of total billed charges HEPATITIS B SURFACE ANTIBODY (HBSAB) 3028670601_1 CDM 302 RC 86706 HCPCS outpatient 106 79.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 94.34 89 999999999 82.68 100.7 percent of total billed charges HEPATITIS B SURFACE ANTIBODY (HBSAB) 3028670601_1 CDM 302 RC 86706 HCPCS outpatient 106 79.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 93.28 88 999999999 82.68 100.7 percent of total billed charges HEPATITIS B SURFACE ANTIBODY (HBSAB) 3028670601_1 CDM 302 RC 86706 HCPCS outpatient 106 79.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 94.34 89 999999999 82.68 100.7 percent of total billed charges HEPATITIS A ANTIBODY (HAAB) 3028670801_1 CDM 302 RC 86708 HCPCS outpatient 93 69.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 83.7 90 999999999 72.54 88.35 percent of total billed charges HEPATITIS A ANTIBODY (HAAB) 3028670801_1 CDM 302 RC 86708 HCPCS outpatient 93 69.75 AETNA MCR ADV AETNA MCR ADV 72.54 78 999999999 72.54 88.35 percent of total billed charges HEPATITIS A ANTIBODY (HAAB) 3028670801_1 CDM 302 RC 86708 HCPCS outpatient 93 69.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 81.44 87.57 999999999 72.54 88.35 percent of total billed charges HEPATITIS A ANTIBODY (HAAB) 3028670801_1 CDM 302 RC 86708 HCPCS outpatient 93 69.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 79.12 85.07 999999999 72.54 88.35 percent of total billed charges HEPATITIS A ANTIBODY (HAAB) 3028670801_1 CDM 302 RC 86708 HCPCS outpatient 93 69.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 79.12 85.07 999999999 72.54 88.35 percent of total billed charges HEPATITIS A ANTIBODY (HAAB) 3028670801_1 CDM 302 RC 86708 HCPCS outpatient 93 69.75 MOLINA MCAID MOLINA MCAID 77.56 83.4 999999999 72.54 88.35 percent of total billed charges HEPATITIS A ANTIBODY (HAAB) 3028670801_1 CDM 302 RC 86708 HCPCS outpatient 93 69.75 MOLINA MCR ADV MOLINA MCR ADV 82.77 89 999999999 72.54 88.35 percent of total billed charges HEPATITIS A ANTIBODY (HAAB) 3028670801_1 CDM 302 RC 86708 HCPCS outpatient 93 69.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 82.77 89 999999999 72.54 88.35 percent of total billed charges HEPATITIS A ANTIBODY (HAAB) 3028670801_1 CDM 302 RC 86708 HCPCS outpatient 93 69.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 82.77 89 999999999 72.54 88.35 percent of total billed charges HEPATITIS A ANTIBODY (HAAB) 3028670801_1 CDM 302 RC 86708 HCPCS outpatient 93 69.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 83.7 90 999999999 72.54 88.35 percent of total billed charges HEPATITIS A ANTIBODY (HAAB) 3028670801_1 CDM 302 RC 86708 HCPCS outpatient 93 69.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 88.35 95 999999999 72.54 88.35 percent of total billed charges HEPATITIS A ANTIBODY (HAAB) 3028670801_1 CDM 302 RC 86708 HCPCS outpatient 93 69.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 88.35 95 999999999 72.54 88.35 percent of total billed charges HEPATITIS A ANTIBODY (HAAB) 3028670801_1 CDM 302 RC 86708 HCPCS outpatient 93 69.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 82.77 89 999999999 72.54 88.35 percent of total billed charges HEPATITIS A ANTIBODY (HAAB) 3028670801_1 CDM 302 RC 86708 HCPCS outpatient 93 69.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 81.84 88 999999999 72.54 88.35 percent of total billed charges HEPATITIS A ANTIBODY (HAAB) 3028670801_1 CDM 302 RC 86708 HCPCS outpatient 93 69.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 82.77 89 999999999 72.54 88.35 percent of total billed charges "HEPATITIS A ANTIBODY (HAAB), IGM ANTIBODY" 3028670901_1 CDM 302 RC 86709 HCPCS outpatient 111 83.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 99.9 90 999999999 86.58 105.45 percent of total billed charges "HEPATITIS A ANTIBODY (HAAB), IGM ANTIBODY" 3028670901_1 CDM 302 RC 86709 HCPCS outpatient 111 83.25 AETNA MCR ADV AETNA MCR ADV 86.58 78 999999999 86.58 105.45 percent of total billed charges "HEPATITIS A ANTIBODY (HAAB), IGM ANTIBODY" 3028670901_1 CDM 302 RC 86709 HCPCS outpatient 111 83.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 97.2 87.57 999999999 86.58 105.45 percent of total billed charges "HEPATITIS A ANTIBODY (HAAB), IGM ANTIBODY" 3028670901_1 CDM 302 RC 86709 HCPCS outpatient 111 83.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 94.43 85.07 999999999 86.58 105.45 percent of total billed charges "HEPATITIS A ANTIBODY (HAAB), IGM ANTIBODY" 3028670901_1 CDM 302 RC 86709 HCPCS outpatient 111 83.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 94.43 85.07 999999999 86.58 105.45 percent of total billed charges "HEPATITIS A ANTIBODY (HAAB), IGM ANTIBODY" 3028670901_1 CDM 302 RC 86709 HCPCS outpatient 111 83.25 MOLINA MCAID MOLINA MCAID 92.57 83.4 999999999 86.58 105.45 percent of total billed charges "HEPATITIS A ANTIBODY (HAAB), IGM ANTIBODY" 3028670901_1 CDM 302 RC 86709 HCPCS outpatient 111 83.25 MOLINA MCR ADV MOLINA MCR ADV 98.79 89 999999999 86.58 105.45 percent of total billed charges "HEPATITIS A ANTIBODY (HAAB), IGM ANTIBODY" 3028670901_1 CDM 302 RC 86709 HCPCS outpatient 111 83.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 98.79 89 999999999 86.58 105.45 percent of total billed charges "HEPATITIS A ANTIBODY (HAAB), IGM ANTIBODY" 3028670901_1 CDM 302 RC 86709 HCPCS outpatient 111 83.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 98.79 89 999999999 86.58 105.45 percent of total billed charges "HEPATITIS A ANTIBODY (HAAB), IGM ANTIBODY" 3028670901_1 CDM 302 RC 86709 HCPCS outpatient 111 83.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 99.9 90 999999999 86.58 105.45 percent of total billed charges "HEPATITIS A ANTIBODY (HAAB), IGM ANTIBODY" 3028670901_1 CDM 302 RC 86709 HCPCS outpatient 111 83.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 105.45 95 999999999 86.58 105.45 percent of total billed charges "HEPATITIS A ANTIBODY (HAAB), IGM ANTIBODY" 3028670901_1 CDM 302 RC 86709 HCPCS outpatient 111 83.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 105.45 95 999999999 86.58 105.45 percent of total billed charges "HEPATITIS A ANTIBODY (HAAB), IGM ANTIBODY" 3028670901_1 CDM 302 RC 86709 HCPCS outpatient 111 83.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 98.79 89 999999999 86.58 105.45 percent of total billed charges "HEPATITIS A ANTIBODY (HAAB), IGM ANTIBODY" 3028670901_1 CDM 302 RC 86709 HCPCS outpatient 111 83.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 97.68 88 999999999 86.58 105.45 percent of total billed charges "HEPATITIS A ANTIBODY (HAAB), IGM ANTIBODY" 3028670901_1 CDM 302 RC 86709 HCPCS outpatient 111 83.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 98.79 89 999999999 86.58 105.45 percent of total billed charges ANTIBODY; MUMPS 3028673501_1 CDM 302 RC 86735 HCPCS outpatient 136 102 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 122.4 90 999999999 106.08 129.2 percent of total billed charges ANTIBODY; MUMPS 3028673501_1 CDM 302 RC 86735 HCPCS outpatient 136 102 AETNA MCR ADV AETNA MCR ADV 106.08 78 999999999 106.08 129.2 percent of total billed charges ANTIBODY; MUMPS 3028673501_1 CDM 302 RC 86735 HCPCS outpatient 136 102 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 119.1 87.57 999999999 106.08 129.2 percent of total billed charges ANTIBODY; MUMPS 3028673501_1 CDM 302 RC 86735 HCPCS outpatient 136 102 COORDINATED CARE MCAID COORDINATED CARE MCAID 115.7 85.07 999999999 106.08 129.2 percent of total billed charges ANTIBODY; MUMPS 3028673501_1 CDM 302 RC 86735 HCPCS outpatient 136 102 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 115.7 85.07 999999999 106.08 129.2 percent of total billed charges ANTIBODY; MUMPS 3028673501_1 CDM 302 RC 86735 HCPCS outpatient 136 102 MOLINA MCAID MOLINA MCAID 113.42 83.4 999999999 106.08 129.2 percent of total billed charges ANTIBODY; MUMPS 3028673501_1 CDM 302 RC 86735 HCPCS outpatient 136 102 MOLINA MCR ADV MOLINA MCR ADV 121.04 89 999999999 106.08 129.2 percent of total billed charges ANTIBODY; MUMPS 3028673501_1 CDM 302 RC 86735 HCPCS outpatient 136 102 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 121.04 89 999999999 106.08 129.2 percent of total billed charges ANTIBODY; MUMPS 3028673501_1 CDM 302 RC 86735 HCPCS outpatient 136 102 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 121.04 89 999999999 106.08 129.2 percent of total billed charges ANTIBODY; MUMPS 3028673501_1 CDM 302 RC 86735 HCPCS outpatient 136 102 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 122.4 90 999999999 106.08 129.2 percent of total billed charges ANTIBODY; MUMPS 3028673501_1 CDM 302 RC 86735 HCPCS outpatient 136 102 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 129.2 95 999999999 106.08 129.2 percent of total billed charges ANTIBODY; MUMPS 3028673501_1 CDM 302 RC 86735 HCPCS outpatient 136 102 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 129.2 95 999999999 106.08 129.2 percent of total billed charges ANTIBODY; MUMPS 3028673501_1 CDM 302 RC 86735 HCPCS outpatient 136 102 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 121.04 89 999999999 106.08 129.2 percent of total billed charges ANTIBODY; MUMPS 3028673501_1 CDM 302 RC 86735 HCPCS outpatient 136 102 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 119.68 88 999999999 106.08 129.2 percent of total billed charges ANTIBODY; MUMPS 3028673501_1 CDM 302 RC 86735 HCPCS outpatient 136 102 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 121.04 89 999999999 106.08 129.2 percent of total billed charges ANTIBODY; RUBELLA 3028676201_1 CDM 302 RC 86762 HCPCS outpatient 153 114.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 137.7 90 999999999 119.34 145.35 percent of total billed charges ANTIBODY; RUBELLA 3028676201_1 CDM 302 RC 86762 HCPCS outpatient 153 114.75 AETNA MCR ADV AETNA MCR ADV 119.34 78 999999999 119.34 145.35 percent of total billed charges ANTIBODY; RUBELLA 3028676201_1 CDM 302 RC 86762 HCPCS outpatient 153 114.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 133.98 87.57 999999999 119.34 145.35 percent of total billed charges ANTIBODY; RUBELLA 3028676201_1 CDM 302 RC 86762 HCPCS outpatient 153 114.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 130.16 85.07 999999999 119.34 145.35 percent of total billed charges ANTIBODY; RUBELLA 3028676201_1 CDM 302 RC 86762 HCPCS outpatient 153 114.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 130.16 85.07 999999999 119.34 145.35 percent of total billed charges ANTIBODY; RUBELLA 3028676201_1 CDM 302 RC 86762 HCPCS outpatient 153 114.75 MOLINA MCAID MOLINA MCAID 127.6 83.4 999999999 119.34 145.35 percent of total billed charges ANTIBODY; RUBELLA 3028676201_1 CDM 302 RC 86762 HCPCS outpatient 153 114.75 MOLINA MCR ADV MOLINA MCR ADV 136.17 89 999999999 119.34 145.35 percent of total billed charges ANTIBODY; RUBELLA 3028676201_1 CDM 302 RC 86762 HCPCS outpatient 153 114.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 136.17 89 999999999 119.34 145.35 percent of total billed charges ANTIBODY; RUBELLA 3028676201_1 CDM 302 RC 86762 HCPCS outpatient 153 114.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 136.17 89 999999999 119.34 145.35 percent of total billed charges ANTIBODY; RUBELLA 3028676201_1 CDM 302 RC 86762 HCPCS outpatient 153 114.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 137.7 90 999999999 119.34 145.35 percent of total billed charges ANTIBODY; RUBELLA 3028676201_1 CDM 302 RC 86762 HCPCS outpatient 153 114.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 145.35 95 999999999 119.34 145.35 percent of total billed charges ANTIBODY; RUBELLA 3028676201_1 CDM 302 RC 86762 HCPCS outpatient 153 114.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 145.35 95 999999999 119.34 145.35 percent of total billed charges ANTIBODY; RUBELLA 3028676201_1 CDM 302 RC 86762 HCPCS outpatient 153 114.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 136.17 89 999999999 119.34 145.35 percent of total billed charges ANTIBODY; RUBELLA 3028676201_1 CDM 302 RC 86762 HCPCS outpatient 153 114.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 134.64 88 999999999 119.34 145.35 percent of total billed charges ANTIBODY; RUBELLA 3028676201_1 CDM 302 RC 86762 HCPCS outpatient 153 114.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 136.17 89 999999999 119.34 145.35 percent of total billed charges ANTIBODY; RUBEOLA 3028676501_1 CDM 302 RC 86765 HCPCS outpatient 135 101.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 121.5 90 999999999 105.3 128.25 percent of total billed charges ANTIBODY; RUBEOLA 3028676501_1 CDM 302 RC 86765 HCPCS outpatient 135 101.25 AETNA MCR ADV AETNA MCR ADV 105.3 78 999999999 105.3 128.25 percent of total billed charges ANTIBODY; RUBEOLA 3028676501_1 CDM 302 RC 86765 HCPCS outpatient 135 101.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 118.22 87.57 999999999 105.3 128.25 percent of total billed charges ANTIBODY; RUBEOLA 3028676501_1 CDM 302 RC 86765 HCPCS outpatient 135 101.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 114.84 85.07 999999999 105.3 128.25 percent of total billed charges ANTIBODY; RUBEOLA 3028676501_1 CDM 302 RC 86765 HCPCS outpatient 135 101.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 114.84 85.07 999999999 105.3 128.25 percent of total billed charges ANTIBODY; RUBEOLA 3028676501_1 CDM 302 RC 86765 HCPCS outpatient 135 101.25 MOLINA MCAID MOLINA MCAID 112.59 83.4 999999999 105.3 128.25 percent of total billed charges ANTIBODY; RUBEOLA 3028676501_1 CDM 302 RC 86765 HCPCS outpatient 135 101.25 MOLINA MCR ADV MOLINA MCR ADV 120.15 89 999999999 105.3 128.25 percent of total billed charges ANTIBODY; RUBEOLA 3028676501_1 CDM 302 RC 86765 HCPCS outpatient 135 101.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 120.15 89 999999999 105.3 128.25 percent of total billed charges ANTIBODY; RUBEOLA 3028676501_1 CDM 302 RC 86765 HCPCS outpatient 135 101.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 120.15 89 999999999 105.3 128.25 percent of total billed charges ANTIBODY; RUBEOLA 3028676501_1 CDM 302 RC 86765 HCPCS outpatient 135 101.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 121.5 90 999999999 105.3 128.25 percent of total billed charges ANTIBODY; RUBEOLA 3028676501_1 CDM 302 RC 86765 HCPCS outpatient 135 101.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 128.25 95 999999999 105.3 128.25 percent of total billed charges ANTIBODY; RUBEOLA 3028676501_1 CDM 302 RC 86765 HCPCS outpatient 135 101.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 128.25 95 999999999 105.3 128.25 percent of total billed charges ANTIBODY; RUBEOLA 3028676501_1 CDM 302 RC 86765 HCPCS outpatient 135 101.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 120.15 89 999999999 105.3 128.25 percent of total billed charges ANTIBODY; RUBEOLA 3028676501_1 CDM 302 RC 86765 HCPCS outpatient 135 101.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 118.8 88 999999999 105.3 128.25 percent of total billed charges ANTIBODY; RUBEOLA 3028676501_1 CDM 302 RC 86765 HCPCS outpatient 135 101.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 120.15 89 999999999 105.3 128.25 percent of total billed charges ANTIBODY; SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) 3028676901_1 CDM 302 RC 86769 HCPCS outpatient 77 57.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 69.3 90 999999999 60.06 73.15 percent of total billed charges ANTIBODY; SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) 3028676901_1 CDM 302 RC 86769 HCPCS outpatient 77 57.75 AETNA MCR ADV AETNA MCR ADV 60.06 78 999999999 60.06 73.15 percent of total billed charges ANTIBODY; SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) 3028676901_1 CDM 302 RC 86769 HCPCS outpatient 77 57.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 67.43 87.57 999999999 60.06 73.15 percent of total billed charges ANTIBODY; SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) 3028676901_1 CDM 302 RC 86769 HCPCS outpatient 77 57.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 65.5 85.07 999999999 60.06 73.15 percent of total billed charges ANTIBODY; SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) 3028676901_1 CDM 302 RC 86769 HCPCS outpatient 77 57.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 65.5 85.07 999999999 60.06 73.15 percent of total billed charges ANTIBODY; SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) 3028676901_1 CDM 302 RC 86769 HCPCS outpatient 77 57.75 MOLINA MCAID MOLINA MCAID 64.22 83.4 999999999 60.06 73.15 percent of total billed charges ANTIBODY; SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) 3028676901_1 CDM 302 RC 86769 HCPCS outpatient 77 57.75 MOLINA MCR ADV MOLINA MCR ADV 68.53 89 999999999 60.06 73.15 percent of total billed charges ANTIBODY; SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) 3028676901_1 CDM 302 RC 86769 HCPCS outpatient 77 57.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 68.53 89 999999999 60.06 73.15 percent of total billed charges ANTIBODY; SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) 3028676901_1 CDM 302 RC 86769 HCPCS outpatient 77 57.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 68.53 89 999999999 60.06 73.15 percent of total billed charges ANTIBODY; SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) 3028676901_1 CDM 302 RC 86769 HCPCS outpatient 77 57.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 69.3 90 999999999 60.06 73.15 percent of total billed charges ANTIBODY; SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) 3028676901_1 CDM 302 RC 86769 HCPCS outpatient 77 57.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 73.15 95 999999999 60.06 73.15 percent of total billed charges ANTIBODY; SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) 3028676901_1 CDM 302 RC 86769 HCPCS outpatient 77 57.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 73.15 95 999999999 60.06 73.15 percent of total billed charges ANTIBODY; SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) 3028676901_1 CDM 302 RC 86769 HCPCS outpatient 77 57.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 68.53 89 999999999 60.06 73.15 percent of total billed charges ANTIBODY; SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) 3028676901_1 CDM 302 RC 86769 HCPCS outpatient 77 57.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 67.76 88 999999999 60.06 73.15 percent of total billed charges ANTIBODY; SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) 3028676901_1 CDM 302 RC 86769 HCPCS outpatient 77 57.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 68.53 89 999999999 60.06 73.15 percent of total billed charges ANTIBODY; TOXOPLASMA 3028677703_1 CDM 302 RC 86777 HCPCS outpatient 143 107.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 128.7 90 999999999 111.54 135.85 percent of total billed charges ANTIBODY; TOXOPLASMA 3028677703_1 CDM 302 RC 86777 HCPCS outpatient 143 107.25 AETNA MCR ADV AETNA MCR ADV 111.54 78 999999999 111.54 135.85 percent of total billed charges ANTIBODY; TOXOPLASMA 3028677703_1 CDM 302 RC 86777 HCPCS outpatient 143 107.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 125.23 87.57 999999999 111.54 135.85 percent of total billed charges ANTIBODY; TOXOPLASMA 3028677703_1 CDM 302 RC 86777 HCPCS outpatient 143 107.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 121.65 85.07 999999999 111.54 135.85 percent of total billed charges ANTIBODY; TOXOPLASMA 3028677703_1 CDM 302 RC 86777 HCPCS outpatient 143 107.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 121.65 85.07 999999999 111.54 135.85 percent of total billed charges ANTIBODY; TOXOPLASMA 3028677703_1 CDM 302 RC 86777 HCPCS outpatient 143 107.25 MOLINA MCAID MOLINA MCAID 119.26 83.4 999999999 111.54 135.85 percent of total billed charges ANTIBODY; TOXOPLASMA 3028677703_1 CDM 302 RC 86777 HCPCS outpatient 143 107.25 MOLINA MCR ADV MOLINA MCR ADV 127.27 89 999999999 111.54 135.85 percent of total billed charges ANTIBODY; TOXOPLASMA 3028677703_1 CDM 302 RC 86777 HCPCS outpatient 143 107.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 127.27 89 999999999 111.54 135.85 percent of total billed charges ANTIBODY; TOXOPLASMA 3028677703_1 CDM 302 RC 86777 HCPCS outpatient 143 107.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 127.27 89 999999999 111.54 135.85 percent of total billed charges ANTIBODY; TOXOPLASMA 3028677703_1 CDM 302 RC 86777 HCPCS outpatient 143 107.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 128.7 90 999999999 111.54 135.85 percent of total billed charges ANTIBODY; TOXOPLASMA 3028677703_1 CDM 302 RC 86777 HCPCS outpatient 143 107.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 135.85 95 999999999 111.54 135.85 percent of total billed charges ANTIBODY; TOXOPLASMA 3028677703_1 CDM 302 RC 86777 HCPCS outpatient 143 107.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 135.85 95 999999999 111.54 135.85 percent of total billed charges ANTIBODY; TOXOPLASMA 3028677703_1 CDM 302 RC 86777 HCPCS outpatient 143 107.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 127.27 89 999999999 111.54 135.85 percent of total billed charges ANTIBODY; TOXOPLASMA 3028677703_1 CDM 302 RC 86777 HCPCS outpatient 143 107.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 125.84 88 999999999 111.54 135.85 percent of total billed charges ANTIBODY; TOXOPLASMA 3028677703_1 CDM 302 RC 86777 HCPCS outpatient 143 107.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 127.27 89 999999999 111.54 135.85 percent of total billed charges "ANTIBODY; TOXOPLASMA, IGM" 3028677803_1 CDM 302 RC 86778 HCPCS outpatient 149 111.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 134.1 90 999999999 116.22 141.55 percent of total billed charges "ANTIBODY; TOXOPLASMA, IGM" 3028677803_1 CDM 302 RC 86778 HCPCS outpatient 149 111.75 AETNA MCR ADV AETNA MCR ADV 116.22 78 999999999 116.22 141.55 percent of total billed charges "ANTIBODY; TOXOPLASMA, IGM" 3028677803_1 CDM 302 RC 86778 HCPCS outpatient 149 111.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 130.48 87.57 999999999 116.22 141.55 percent of total billed charges "ANTIBODY; TOXOPLASMA, IGM" 3028677803_1 CDM 302 RC 86778 HCPCS outpatient 149 111.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 126.75 85.07 999999999 116.22 141.55 percent of total billed charges "ANTIBODY; TOXOPLASMA, IGM" 3028677803_1 CDM 302 RC 86778 HCPCS outpatient 149 111.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 126.75 85.07 999999999 116.22 141.55 percent of total billed charges "ANTIBODY; TOXOPLASMA, IGM" 3028677803_1 CDM 302 RC 86778 HCPCS outpatient 149 111.75 MOLINA MCAID MOLINA MCAID 124.27 83.4 999999999 116.22 141.55 percent of total billed charges "ANTIBODY; TOXOPLASMA, IGM" 3028677803_1 CDM 302 RC 86778 HCPCS outpatient 149 111.75 MOLINA MCR ADV MOLINA MCR ADV 132.61 89 999999999 116.22 141.55 percent of total billed charges "ANTIBODY; TOXOPLASMA, IGM" 3028677803_1 CDM 302 RC 86778 HCPCS outpatient 149 111.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 132.61 89 999999999 116.22 141.55 percent of total billed charges "ANTIBODY; TOXOPLASMA, IGM" 3028677803_1 CDM 302 RC 86778 HCPCS outpatient 149 111.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 132.61 89 999999999 116.22 141.55 percent of total billed charges "ANTIBODY; TOXOPLASMA, IGM" 3028677803_1 CDM 302 RC 86778 HCPCS outpatient 149 111.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 134.1 90 999999999 116.22 141.55 percent of total billed charges "ANTIBODY; TOXOPLASMA, IGM" 3028677803_1 CDM 302 RC 86778 HCPCS outpatient 149 111.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 141.55 95 999999999 116.22 141.55 percent of total billed charges "ANTIBODY; TOXOPLASMA, IGM" 3028677803_1 CDM 302 RC 86778 HCPCS outpatient 149 111.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 141.55 95 999999999 116.22 141.55 percent of total billed charges "ANTIBODY; TOXOPLASMA, IGM" 3028677803_1 CDM 302 RC 86778 HCPCS outpatient 149 111.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 132.61 89 999999999 116.22 141.55 percent of total billed charges "ANTIBODY; TOXOPLASMA, IGM" 3028677803_1 CDM 302 RC 86778 HCPCS outpatient 149 111.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 131.12 88 999999999 116.22 141.55 percent of total billed charges "ANTIBODY; TOXOPLASMA, IGM" 3028677803_1 CDM 302 RC 86778 HCPCS outpatient 149 111.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 132.61 89 999999999 116.22 141.55 percent of total billed charges ANTIBODY; TREPONEMA PALLIDUM 3028678004_1 CDM 302 RC 86780 HCPCS outpatient 85 63.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 76.5 90 999999999 66.3 80.75 percent of total billed charges ANTIBODY; TREPONEMA PALLIDUM 3028678004_1 CDM 302 RC 86780 HCPCS outpatient 85 63.75 AETNA MCR ADV AETNA MCR ADV 66.3 78 999999999 66.3 80.75 percent of total billed charges ANTIBODY; TREPONEMA PALLIDUM 3028678004_1 CDM 302 RC 86780 HCPCS outpatient 85 63.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 74.43 87.57 999999999 66.3 80.75 percent of total billed charges ANTIBODY; TREPONEMA PALLIDUM 3028678004_1 CDM 302 RC 86780 HCPCS outpatient 85 63.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 72.31 85.07 999999999 66.3 80.75 percent of total billed charges ANTIBODY; TREPONEMA PALLIDUM 3028678004_1 CDM 302 RC 86780 HCPCS outpatient 85 63.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 72.31 85.07 999999999 66.3 80.75 percent of total billed charges ANTIBODY; TREPONEMA PALLIDUM 3028678004_1 CDM 302 RC 86780 HCPCS outpatient 85 63.75 MOLINA MCAID MOLINA MCAID 70.89 83.4 999999999 66.3 80.75 percent of total billed charges ANTIBODY; TREPONEMA PALLIDUM 3028678004_1 CDM 302 RC 86780 HCPCS outpatient 85 63.75 MOLINA MCR ADV MOLINA MCR ADV 75.65 89 999999999 66.3 80.75 percent of total billed charges ANTIBODY; TREPONEMA PALLIDUM 3028678004_1 CDM 302 RC 86780 HCPCS outpatient 85 63.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 75.65 89 999999999 66.3 80.75 percent of total billed charges ANTIBODY; TREPONEMA PALLIDUM 3028678004_1 CDM 302 RC 86780 HCPCS outpatient 85 63.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 75.65 89 999999999 66.3 80.75 percent of total billed charges ANTIBODY; TREPONEMA PALLIDUM 3028678004_1 CDM 302 RC 86780 HCPCS outpatient 85 63.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 76.5 90 999999999 66.3 80.75 percent of total billed charges ANTIBODY; TREPONEMA PALLIDUM 3028678004_1 CDM 302 RC 86780 HCPCS outpatient 85 63.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 80.75 95 999999999 66.3 80.75 percent of total billed charges ANTIBODY; TREPONEMA PALLIDUM 3028678004_1 CDM 302 RC 86780 HCPCS outpatient 85 63.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 80.75 95 999999999 66.3 80.75 percent of total billed charges ANTIBODY; TREPONEMA PALLIDUM 3028678004_1 CDM 302 RC 86780 HCPCS outpatient 85 63.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 75.65 89 999999999 66.3 80.75 percent of total billed charges ANTIBODY; TREPONEMA PALLIDUM 3028678004_1 CDM 302 RC 86780 HCPCS outpatient 85 63.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 74.8 88 999999999 66.3 80.75 percent of total billed charges ANTIBODY; TREPONEMA PALLIDUM 3028678004_1 CDM 302 RC 86780 HCPCS outpatient 85 63.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 75.65 89 999999999 66.3 80.75 percent of total billed charges ANTIBODY; VARICELLA-ZOSTER 3028678701_1 CDM 302 RC 86787 HCPCS outpatient 151 113.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 135.9 90 999999999 117.78 143.45 percent of total billed charges ANTIBODY; VARICELLA-ZOSTER 3028678701_1 CDM 302 RC 86787 HCPCS outpatient 151 113.25 AETNA MCR ADV AETNA MCR ADV 117.78 78 999999999 117.78 143.45 percent of total billed charges ANTIBODY; VARICELLA-ZOSTER 3028678701_1 CDM 302 RC 86787 HCPCS outpatient 151 113.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 132.23 87.57 999999999 117.78 143.45 percent of total billed charges ANTIBODY; VARICELLA-ZOSTER 3028678701_1 CDM 302 RC 86787 HCPCS outpatient 151 113.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 128.46 85.07 999999999 117.78 143.45 percent of total billed charges ANTIBODY; VARICELLA-ZOSTER 3028678701_1 CDM 302 RC 86787 HCPCS outpatient 151 113.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 128.46 85.07 999999999 117.78 143.45 percent of total billed charges ANTIBODY; VARICELLA-ZOSTER 3028678701_1 CDM 302 RC 86787 HCPCS outpatient 151 113.25 MOLINA MCAID MOLINA MCAID 125.93 83.4 999999999 117.78 143.45 percent of total billed charges ANTIBODY; VARICELLA-ZOSTER 3028678701_1 CDM 302 RC 86787 HCPCS outpatient 151 113.25 MOLINA MCR ADV MOLINA MCR ADV 134.39 89 999999999 117.78 143.45 percent of total billed charges ANTIBODY; VARICELLA-ZOSTER 3028678701_1 CDM 302 RC 86787 HCPCS outpatient 151 113.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 134.39 89 999999999 117.78 143.45 percent of total billed charges ANTIBODY; VARICELLA-ZOSTER 3028678701_1 CDM 302 RC 86787 HCPCS outpatient 151 113.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 134.39 89 999999999 117.78 143.45 percent of total billed charges ANTIBODY; VARICELLA-ZOSTER 3028678701_1 CDM 302 RC 86787 HCPCS outpatient 151 113.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 135.9 90 999999999 117.78 143.45 percent of total billed charges ANTIBODY; VARICELLA-ZOSTER 3028678701_1 CDM 302 RC 86787 HCPCS outpatient 151 113.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 143.45 95 999999999 117.78 143.45 percent of total billed charges ANTIBODY; VARICELLA-ZOSTER 3028678701_1 CDM 302 RC 86787 HCPCS outpatient 151 113.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 143.45 95 999999999 117.78 143.45 percent of total billed charges ANTIBODY; VARICELLA-ZOSTER 3028678701_1 CDM 302 RC 86787 HCPCS outpatient 151 113.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 134.39 89 999999999 117.78 143.45 percent of total billed charges ANTIBODY; VARICELLA-ZOSTER 3028678701_1 CDM 302 RC 86787 HCPCS outpatient 151 113.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 132.88 88 999999999 117.78 143.45 percent of total billed charges ANTIBODY; VARICELLA-ZOSTER 3028678701_1 CDM 302 RC 86787 HCPCS outpatient 151 113.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 134.39 89 999999999 117.78 143.45 percent of total billed charges ANTIBODY; VARICELLA-ZOSTER 3028678704_1 CDM 302 RC 86787 HCPCS outpatient 151 113.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 135.9 90 999999999 117.78 143.45 percent of total billed charges ANTIBODY; VARICELLA-ZOSTER 3028678704_1 CDM 302 RC 86787 HCPCS outpatient 151 113.25 AETNA MCR ADV AETNA MCR ADV 117.78 78 999999999 117.78 143.45 percent of total billed charges ANTIBODY; VARICELLA-ZOSTER 3028678704_1 CDM 302 RC 86787 HCPCS outpatient 151 113.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 132.23 87.57 999999999 117.78 143.45 percent of total billed charges ANTIBODY; VARICELLA-ZOSTER 3028678704_1 CDM 302 RC 86787 HCPCS outpatient 151 113.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 128.46 85.07 999999999 117.78 143.45 percent of total billed charges ANTIBODY; VARICELLA-ZOSTER 3028678704_1 CDM 302 RC 86787 HCPCS outpatient 151 113.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 128.46 85.07 999999999 117.78 143.45 percent of total billed charges ANTIBODY; VARICELLA-ZOSTER 3028678704_1 CDM 302 RC 86787 HCPCS outpatient 151 113.25 MOLINA MCAID MOLINA MCAID 125.93 83.4 999999999 117.78 143.45 percent of total billed charges ANTIBODY; VARICELLA-ZOSTER 3028678704_1 CDM 302 RC 86787 HCPCS outpatient 151 113.25 MOLINA MCR ADV MOLINA MCR ADV 134.39 89 999999999 117.78 143.45 percent of total billed charges ANTIBODY; VARICELLA-ZOSTER 3028678704_1 CDM 302 RC 86787 HCPCS outpatient 151 113.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 134.39 89 999999999 117.78 143.45 percent of total billed charges ANTIBODY; VARICELLA-ZOSTER 3028678704_1 CDM 302 RC 86787 HCPCS outpatient 151 113.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 134.39 89 999999999 117.78 143.45 percent of total billed charges ANTIBODY; VARICELLA-ZOSTER 3028678704_1 CDM 302 RC 86787 HCPCS outpatient 151 113.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 135.9 90 999999999 117.78 143.45 percent of total billed charges ANTIBODY; VARICELLA-ZOSTER 3028678704_1 CDM 302 RC 86787 HCPCS outpatient 151 113.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 143.45 95 999999999 117.78 143.45 percent of total billed charges ANTIBODY; VARICELLA-ZOSTER 3028678704_1 CDM 302 RC 86787 HCPCS outpatient 151 113.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 143.45 95 999999999 117.78 143.45 percent of total billed charges ANTIBODY; VARICELLA-ZOSTER 3028678704_1 CDM 302 RC 86787 HCPCS outpatient 151 113.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 134.39 89 999999999 117.78 143.45 percent of total billed charges ANTIBODY; VARICELLA-ZOSTER 3028678704_1 CDM 302 RC 86787 HCPCS outpatient 151 113.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 132.88 88 999999999 117.78 143.45 percent of total billed charges ANTIBODY; VARICELLA-ZOSTER 3028678704_1 CDM 302 RC 86787 HCPCS outpatient 151 113.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 134.39 89 999999999 117.78 143.45 percent of total billed charges THYROGLOBULIN ANTIBODY 3028680003_1 CDM 302 RC 86800 HCPCS outpatient 137 102.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 123.3 90 999999999 106.86 130.15 percent of total billed charges THYROGLOBULIN ANTIBODY 3028680003_1 CDM 302 RC 86800 HCPCS outpatient 137 102.75 AETNA MCR ADV AETNA MCR ADV 106.86 78 999999999 106.86 130.15 percent of total billed charges THYROGLOBULIN ANTIBODY 3028680003_1 CDM 302 RC 86800 HCPCS outpatient 137 102.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 119.97 87.57 999999999 106.86 130.15 percent of total billed charges THYROGLOBULIN ANTIBODY 3028680003_1 CDM 302 RC 86800 HCPCS outpatient 137 102.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 116.55 85.07 999999999 106.86 130.15 percent of total billed charges THYROGLOBULIN ANTIBODY 3028680003_1 CDM 302 RC 86800 HCPCS outpatient 137 102.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 116.55 85.07 999999999 106.86 130.15 percent of total billed charges THYROGLOBULIN ANTIBODY 3028680003_1 CDM 302 RC 86800 HCPCS outpatient 137 102.75 MOLINA MCAID MOLINA MCAID 114.26 83.4 999999999 106.86 130.15 percent of total billed charges THYROGLOBULIN ANTIBODY 3028680003_1 CDM 302 RC 86800 HCPCS outpatient 137 102.75 MOLINA MCR ADV MOLINA MCR ADV 121.93 89 999999999 106.86 130.15 percent of total billed charges THYROGLOBULIN ANTIBODY 3028680003_1 CDM 302 RC 86800 HCPCS outpatient 137 102.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 121.93 89 999999999 106.86 130.15 percent of total billed charges THYROGLOBULIN ANTIBODY 3028680003_1 CDM 302 RC 86800 HCPCS outpatient 137 102.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 121.93 89 999999999 106.86 130.15 percent of total billed charges THYROGLOBULIN ANTIBODY 3028680003_1 CDM 302 RC 86800 HCPCS outpatient 137 102.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 123.3 90 999999999 106.86 130.15 percent of total billed charges THYROGLOBULIN ANTIBODY 3028680003_1 CDM 302 RC 86800 HCPCS outpatient 137 102.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 130.15 95 999999999 106.86 130.15 percent of total billed charges THYROGLOBULIN ANTIBODY 3028680003_1 CDM 302 RC 86800 HCPCS outpatient 137 102.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 130.15 95 999999999 106.86 130.15 percent of total billed charges THYROGLOBULIN ANTIBODY 3028680003_1 CDM 302 RC 86800 HCPCS outpatient 137 102.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 121.93 89 999999999 106.86 130.15 percent of total billed charges THYROGLOBULIN ANTIBODY 3028680003_1 CDM 302 RC 86800 HCPCS outpatient 137 102.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 120.56 88 999999999 106.86 130.15 percent of total billed charges THYROGLOBULIN ANTIBODY 3028680003_1 CDM 302 RC 86800 HCPCS outpatient 137 102.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 121.93 89 999999999 106.86 130.15 percent of total billed charges HEPATITIS C ANTIBODY 3028680301_1 CDM 302 RC 86803 HCPCS outpatient 146 109.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 131.4 90 999999999 113.88 138.7 percent of total billed charges HEPATITIS C ANTIBODY 3028680301_1 CDM 302 RC 86803 HCPCS outpatient 146 109.5 AETNA MCR ADV AETNA MCR ADV 113.88 78 999999999 113.88 138.7 percent of total billed charges HEPATITIS C ANTIBODY 3028680301_1 CDM 302 RC 86803 HCPCS outpatient 146 109.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 127.85 87.57 999999999 113.88 138.7 percent of total billed charges HEPATITIS C ANTIBODY 3028680301_1 CDM 302 RC 86803 HCPCS outpatient 146 109.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 124.2 85.07 999999999 113.88 138.7 percent of total billed charges HEPATITIS C ANTIBODY 3028680301_1 CDM 302 RC 86803 HCPCS outpatient 146 109.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 124.2 85.07 999999999 113.88 138.7 percent of total billed charges HEPATITIS C ANTIBODY 3028680301_1 CDM 302 RC 86803 HCPCS outpatient 146 109.5 MOLINA MCAID MOLINA MCAID 121.76 83.4 999999999 113.88 138.7 percent of total billed charges HEPATITIS C ANTIBODY 3028680301_1 CDM 302 RC 86803 HCPCS outpatient 146 109.5 MOLINA MCR ADV MOLINA MCR ADV 129.94 89 999999999 113.88 138.7 percent of total billed charges HEPATITIS C ANTIBODY 3028680301_1 CDM 302 RC 86803 HCPCS outpatient 146 109.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 129.94 89 999999999 113.88 138.7 percent of total billed charges HEPATITIS C ANTIBODY 3028680301_1 CDM 302 RC 86803 HCPCS outpatient 146 109.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 129.94 89 999999999 113.88 138.7 percent of total billed charges HEPATITIS C ANTIBODY 3028680301_1 CDM 302 RC 86803 HCPCS outpatient 146 109.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 131.4 90 999999999 113.88 138.7 percent of total billed charges HEPATITIS C ANTIBODY 3028680301_1 CDM 302 RC 86803 HCPCS outpatient 146 109.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 138.7 95 999999999 113.88 138.7 percent of total billed charges HEPATITIS C ANTIBODY 3028680301_1 CDM 302 RC 86803 HCPCS outpatient 146 109.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 138.7 95 999999999 113.88 138.7 percent of total billed charges HEPATITIS C ANTIBODY 3028680301_1 CDM 302 RC 86803 HCPCS outpatient 146 109.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 129.94 89 999999999 113.88 138.7 percent of total billed charges HEPATITIS C ANTIBODY 3028680301_1 CDM 302 RC 86803 HCPCS outpatient 146 109.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 128.48 88 999999999 113.88 138.7 percent of total billed charges HEPATITIS C ANTIBODY 3028680301_1 CDM 302 RC 86803 HCPCS outpatient 146 109.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 129.94 89 999999999 113.88 138.7 percent of total billed charges "HLA TYPING; A, B, OR C (EG, A10, B7, B27), SINGLE ANTIGEN" 3028681202_1 CDM 302 RC 86812 HCPCS outpatient 219 164.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 197.1 90 999999999 170.82 208.05 percent of total billed charges "HLA TYPING; A, B, OR C (EG, A10, B7, B27), SINGLE ANTIGEN" 3028681202_1 CDM 302 RC 86812 HCPCS outpatient 219 164.25 AETNA MCR ADV AETNA MCR ADV 170.82 78 999999999 170.82 208.05 percent of total billed charges "HLA TYPING; A, B, OR C (EG, A10, B7, B27), SINGLE ANTIGEN" 3028681202_1 CDM 302 RC 86812 HCPCS outpatient 219 164.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 191.78 87.57 999999999 170.82 208.05 percent of total billed charges "HLA TYPING; A, B, OR C (EG, A10, B7, B27), SINGLE ANTIGEN" 3028681202_1 CDM 302 RC 86812 HCPCS outpatient 219 164.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 186.3 85.07 999999999 170.82 208.05 percent of total billed charges "HLA TYPING; A, B, OR C (EG, A10, B7, B27), SINGLE ANTIGEN" 3028681202_1 CDM 302 RC 86812 HCPCS outpatient 219 164.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 186.3 85.07 999999999 170.82 208.05 percent of total billed charges "HLA TYPING; A, B, OR C (EG, A10, B7, B27), SINGLE ANTIGEN" 3028681202_1 CDM 302 RC 86812 HCPCS outpatient 219 164.25 MOLINA MCAID MOLINA MCAID 182.65 83.4 999999999 170.82 208.05 percent of total billed charges "HLA TYPING; A, B, OR C (EG, A10, B7, B27), SINGLE ANTIGEN" 3028681202_1 CDM 302 RC 86812 HCPCS outpatient 219 164.25 MOLINA MCR ADV MOLINA MCR ADV 194.91 89 999999999 170.82 208.05 percent of total billed charges "HLA TYPING; A, B, OR C (EG, A10, B7, B27), SINGLE ANTIGEN" 3028681202_1 CDM 302 RC 86812 HCPCS outpatient 219 164.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 194.91 89 999999999 170.82 208.05 percent of total billed charges "HLA TYPING; A, B, OR C (EG, A10, B7, B27), SINGLE ANTIGEN" 3028681202_1 CDM 302 RC 86812 HCPCS outpatient 219 164.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 194.91 89 999999999 170.82 208.05 percent of total billed charges "HLA TYPING; A, B, OR C (EG, A10, B7, B27), SINGLE ANTIGEN" 3028681202_1 CDM 302 RC 86812 HCPCS outpatient 219 164.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 197.1 90 999999999 170.82 208.05 percent of total billed charges "HLA TYPING; A, B, OR C (EG, A10, B7, B27), SINGLE ANTIGEN" 3028681202_1 CDM 302 RC 86812 HCPCS outpatient 219 164.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 208.05 95 999999999 170.82 208.05 percent of total billed charges "HLA TYPING; A, B, OR C (EG, A10, B7, B27), SINGLE ANTIGEN" 3028681202_1 CDM 302 RC 86812 HCPCS outpatient 219 164.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 208.05 95 999999999 170.82 208.05 percent of total billed charges "HLA TYPING; A, B, OR C (EG, A10, B7, B27), SINGLE ANTIGEN" 3028681202_1 CDM 302 RC 86812 HCPCS outpatient 219 164.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 194.91 89 999999999 170.82 208.05 percent of total billed charges "HLA TYPING; A, B, OR C (EG, A10, B7, B27), SINGLE ANTIGEN" 3028681202_1 CDM 302 RC 86812 HCPCS outpatient 219 164.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 192.72 88 999999999 170.82 208.05 percent of total billed charges "HLA TYPING; A, B, OR C (EG, A10, B7, B27), SINGLE ANTIGEN" 3028681202_1 CDM 302 RC 86812 HCPCS outpatient 219 164.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 194.91 89 999999999 170.82 208.05 percent of total billed charges "HLA TYPING; A, B, OR C, MULTIPLE ANTIGENS" 3028681301_1 CDM 302 RC 86813 HCPCS outpatient 479 359.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 431.1 90 999999999 373.62 455.05 percent of total billed charges "HLA TYPING; A, B, OR C, MULTIPLE ANTIGENS" 3028681301_1 CDM 302 RC 86813 HCPCS outpatient 479 359.25 AETNA MCR ADV AETNA MCR ADV 373.62 78 999999999 373.62 455.05 percent of total billed charges "HLA TYPING; A, B, OR C, MULTIPLE ANTIGENS" 3028681301_1 CDM 302 RC 86813 HCPCS outpatient 479 359.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 419.46 87.57 999999999 373.62 455.05 percent of total billed charges "HLA TYPING; A, B, OR C, MULTIPLE ANTIGENS" 3028681301_1 CDM 302 RC 86813 HCPCS outpatient 479 359.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 407.49 85.07 999999999 373.62 455.05 percent of total billed charges "HLA TYPING; A, B, OR C, MULTIPLE ANTIGENS" 3028681301_1 CDM 302 RC 86813 HCPCS outpatient 479 359.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 407.49 85.07 999999999 373.62 455.05 percent of total billed charges "HLA TYPING; A, B, OR C, MULTIPLE ANTIGENS" 3028681301_1 CDM 302 RC 86813 HCPCS outpatient 479 359.25 MOLINA MCAID MOLINA MCAID 399.49 83.4 999999999 373.62 455.05 percent of total billed charges "HLA TYPING; A, B, OR C, MULTIPLE ANTIGENS" 3028681301_1 CDM 302 RC 86813 HCPCS outpatient 479 359.25 MOLINA MCR ADV MOLINA MCR ADV 426.31 89 999999999 373.62 455.05 percent of total billed charges "HLA TYPING; A, B, OR C, MULTIPLE ANTIGENS" 3028681301_1 CDM 302 RC 86813 HCPCS outpatient 479 359.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 426.31 89 999999999 373.62 455.05 percent of total billed charges "HLA TYPING; A, B, OR C, MULTIPLE ANTIGENS" 3028681301_1 CDM 302 RC 86813 HCPCS outpatient 479 359.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 426.31 89 999999999 373.62 455.05 percent of total billed charges "HLA TYPING; A, B, OR C, MULTIPLE ANTIGENS" 3028681301_1 CDM 302 RC 86813 HCPCS outpatient 479 359.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 431.1 90 999999999 373.62 455.05 percent of total billed charges "HLA TYPING; A, B, OR C, MULTIPLE ANTIGENS" 3028681301_1 CDM 302 RC 86813 HCPCS outpatient 479 359.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 455.05 95 999999999 373.62 455.05 percent of total billed charges "HLA TYPING; A, B, OR C, MULTIPLE ANTIGENS" 3028681301_1 CDM 302 RC 86813 HCPCS outpatient 479 359.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 455.05 95 999999999 373.62 455.05 percent of total billed charges "HLA TYPING; A, B, OR C, MULTIPLE ANTIGENS" 3028681301_1 CDM 302 RC 86813 HCPCS outpatient 479 359.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 426.31 89 999999999 373.62 455.05 percent of total billed charges "HLA TYPING; A, B, OR C, MULTIPLE ANTIGENS" 3028681301_1 CDM 302 RC 86813 HCPCS outpatient 479 359.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 421.52 88 999999999 373.62 455.05 percent of total billed charges "HLA TYPING; A, B, OR C, MULTIPLE ANTIGENS" 3028681301_1 CDM 302 RC 86813 HCPCS outpatient 479 359.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 426.31 89 999999999 373.62 455.05 percent of total billed charges "ANTIBODY SCREEN, RBC, EACH SERUM TECHNIQUE" 3028685001_1 CDM 302 RC 86850 HCPCS outpatient 112 84 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 100.8 90 999999999 87.36 106.4 percent of total billed charges "ANTIBODY SCREEN, RBC, EACH SERUM TECHNIQUE" 3028685001_1 CDM 302 RC 86850 HCPCS outpatient 112 84 AETNA MCR ADV AETNA MCR ADV 87.36 78 999999999 87.36 106.4 percent of total billed charges "ANTIBODY SCREEN, RBC, EACH SERUM TECHNIQUE" 3028685001_1 CDM 302 RC 86850 HCPCS outpatient 112 84 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 98.08 87.57 999999999 87.36 106.4 percent of total billed charges "ANTIBODY SCREEN, RBC, EACH SERUM TECHNIQUE" 3028685001_1 CDM 302 RC 86850 HCPCS outpatient 112 84 COORDINATED CARE MCAID COORDINATED CARE MCAID 95.28 85.07 999999999 87.36 106.4 percent of total billed charges "ANTIBODY SCREEN, RBC, EACH SERUM TECHNIQUE" 3028685001_1 CDM 302 RC 86850 HCPCS outpatient 112 84 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 95.28 85.07 999999999 87.36 106.4 percent of total billed charges "ANTIBODY SCREEN, RBC, EACH SERUM TECHNIQUE" 3028685001_1 CDM 302 RC 86850 HCPCS outpatient 112 84 MOLINA MCAID MOLINA MCAID 93.41 83.4 999999999 87.36 106.4 percent of total billed charges "ANTIBODY SCREEN, RBC, EACH SERUM TECHNIQUE" 3028685001_1 CDM 302 RC 86850 HCPCS outpatient 112 84 MOLINA MCR ADV MOLINA MCR ADV 99.68 89 999999999 87.36 106.4 percent of total billed charges "ANTIBODY SCREEN, RBC, EACH SERUM TECHNIQUE" 3028685001_1 CDM 302 RC 86850 HCPCS outpatient 112 84 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 99.68 89 999999999 87.36 106.4 percent of total billed charges "ANTIBODY SCREEN, RBC, EACH SERUM TECHNIQUE" 3028685001_1 CDM 302 RC 86850 HCPCS outpatient 112 84 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 99.68 89 999999999 87.36 106.4 percent of total billed charges "ANTIBODY SCREEN, RBC, EACH SERUM TECHNIQUE" 3028685001_1 CDM 302 RC 86850 HCPCS outpatient 112 84 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 100.8 90 999999999 87.36 106.4 percent of total billed charges "ANTIBODY SCREEN, RBC, EACH SERUM TECHNIQUE" 3028685001_1 CDM 302 RC 86850 HCPCS outpatient 112 84 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 106.4 95 999999999 87.36 106.4 percent of total billed charges "ANTIBODY SCREEN, RBC, EACH SERUM TECHNIQUE" 3028685001_1 CDM 302 RC 86850 HCPCS outpatient 112 84 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 106.4 95 999999999 87.36 106.4 percent of total billed charges "ANTIBODY SCREEN, RBC, EACH SERUM TECHNIQUE" 3028685001_1 CDM 302 RC 86850 HCPCS outpatient 112 84 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 99.68 89 999999999 87.36 106.4 percent of total billed charges "ANTIBODY SCREEN, RBC, EACH SERUM TECHNIQUE" 3028685001_1 CDM 302 RC 86850 HCPCS outpatient 112 84 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 98.56 88 999999999 87.36 106.4 percent of total billed charges "ANTIBODY SCREEN, RBC, EACH SERUM TECHNIQUE" 3028685001_1 CDM 302 RC 86850 HCPCS outpatient 112 84 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 99.68 89 999999999 87.36 106.4 percent of total billed charges "ANTIBODY IDENTIFICATION, RBC ANTIBODIES, EACH PANEL FOR EACH SERUM TECHNIQUE" 3028687001_1 CDM 302 RC 86870 HCPCS outpatient 238 178.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 214.2 90 999999999 185.64 226.1 percent of total billed charges "ANTIBODY IDENTIFICATION, RBC ANTIBODIES, EACH PANEL FOR EACH SERUM TECHNIQUE" 3028687001_1 CDM 302 RC 86870 HCPCS outpatient 238 178.5 AETNA MCR ADV AETNA MCR ADV 185.64 78 999999999 185.64 226.1 percent of total billed charges "ANTIBODY IDENTIFICATION, RBC ANTIBODIES, EACH PANEL FOR EACH SERUM TECHNIQUE" 3028687001_1 CDM 302 RC 86870 HCPCS outpatient 238 178.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 208.42 87.57 999999999 185.64 226.1 percent of total billed charges "ANTIBODY IDENTIFICATION, RBC ANTIBODIES, EACH PANEL FOR EACH SERUM TECHNIQUE" 3028687001_1 CDM 302 RC 86870 HCPCS outpatient 238 178.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 202.47 85.07 999999999 185.64 226.1 percent of total billed charges "ANTIBODY IDENTIFICATION, RBC ANTIBODIES, EACH PANEL FOR EACH SERUM TECHNIQUE" 3028687001_1 CDM 302 RC 86870 HCPCS outpatient 238 178.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 202.47 85.07 999999999 185.64 226.1 percent of total billed charges "ANTIBODY IDENTIFICATION, RBC ANTIBODIES, EACH PANEL FOR EACH SERUM TECHNIQUE" 3028687001_1 CDM 302 RC 86870 HCPCS outpatient 238 178.5 MOLINA MCAID MOLINA MCAID 198.49 83.4 999999999 185.64 226.1 percent of total billed charges "ANTIBODY IDENTIFICATION, RBC ANTIBODIES, EACH PANEL FOR EACH SERUM TECHNIQUE" 3028687001_1 CDM 302 RC 86870 HCPCS outpatient 238 178.5 MOLINA MCR ADV MOLINA MCR ADV 211.82 89 999999999 185.64 226.1 percent of total billed charges "ANTIBODY IDENTIFICATION, RBC ANTIBODIES, EACH PANEL FOR EACH SERUM TECHNIQUE" 3028687001_1 CDM 302 RC 86870 HCPCS outpatient 238 178.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 211.82 89 999999999 185.64 226.1 percent of total billed charges "ANTIBODY IDENTIFICATION, RBC ANTIBODIES, EACH PANEL FOR EACH SERUM TECHNIQUE" 3028687001_1 CDM 302 RC 86870 HCPCS outpatient 238 178.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 211.82 89 999999999 185.64 226.1 percent of total billed charges "ANTIBODY IDENTIFICATION, RBC ANTIBODIES, EACH PANEL FOR EACH SERUM TECHNIQUE" 3028687001_1 CDM 302 RC 86870 HCPCS outpatient 238 178.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 214.2 90 999999999 185.64 226.1 percent of total billed charges "ANTIBODY IDENTIFICATION, RBC ANTIBODIES, EACH PANEL FOR EACH SERUM TECHNIQUE" 3028687001_1 CDM 302 RC 86870 HCPCS outpatient 238 178.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 226.1 95 999999999 185.64 226.1 percent of total billed charges "ANTIBODY IDENTIFICATION, RBC ANTIBODIES, EACH PANEL FOR EACH SERUM TECHNIQUE" 3028687001_1 CDM 302 RC 86870 HCPCS outpatient 238 178.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 226.1 95 999999999 185.64 226.1 percent of total billed charges "ANTIBODY IDENTIFICATION, RBC ANTIBODIES, EACH PANEL FOR EACH SERUM TECHNIQUE" 3028687001_1 CDM 302 RC 86870 HCPCS outpatient 238 178.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 211.82 89 999999999 185.64 226.1 percent of total billed charges "ANTIBODY IDENTIFICATION, RBC ANTIBODIES, EACH PANEL FOR EACH SERUM TECHNIQUE" 3028687001_1 CDM 302 RC 86870 HCPCS outpatient 238 178.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 209.44 88 999999999 185.64 226.1 percent of total billed charges "ANTIBODY IDENTIFICATION, RBC ANTIBODIES, EACH PANEL FOR EACH SERUM TECHNIQUE" 3028687001_1 CDM 302 RC 86870 HCPCS outpatient 238 178.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 211.82 89 999999999 185.64 226.1 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); DIRECT, EACH ANTISERUM" 3028688001_1 CDM 302 RC 86880 HCPCS outpatient 92 69 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 82.8 90 999999999 71.76 87.4 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); DIRECT, EACH ANTISERUM" 3028688001_1 CDM 302 RC 86880 HCPCS outpatient 92 69 AETNA MCR ADV AETNA MCR ADV 71.76 78 999999999 71.76 87.4 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); DIRECT, EACH ANTISERUM" 3028688001_1 CDM 302 RC 86880 HCPCS outpatient 92 69 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 80.56 87.57 999999999 71.76 87.4 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); DIRECT, EACH ANTISERUM" 3028688001_1 CDM 302 RC 86880 HCPCS outpatient 92 69 COORDINATED CARE MCAID COORDINATED CARE MCAID 78.26 85.07 999999999 71.76 87.4 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); DIRECT, EACH ANTISERUM" 3028688001_1 CDM 302 RC 86880 HCPCS outpatient 92 69 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 78.26 85.07 999999999 71.76 87.4 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); DIRECT, EACH ANTISERUM" 3028688001_1 CDM 302 RC 86880 HCPCS outpatient 92 69 MOLINA MCAID MOLINA MCAID 76.73 83.4 999999999 71.76 87.4 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); DIRECT, EACH ANTISERUM" 3028688001_1 CDM 302 RC 86880 HCPCS outpatient 92 69 MOLINA MCR ADV MOLINA MCR ADV 81.88 89 999999999 71.76 87.4 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); DIRECT, EACH ANTISERUM" 3028688001_1 CDM 302 RC 86880 HCPCS outpatient 92 69 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 81.88 89 999999999 71.76 87.4 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); DIRECT, EACH ANTISERUM" 3028688001_1 CDM 302 RC 86880 HCPCS outpatient 92 69 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 81.88 89 999999999 71.76 87.4 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); DIRECT, EACH ANTISERUM" 3028688001_1 CDM 302 RC 86880 HCPCS outpatient 92 69 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 82.8 90 999999999 71.76 87.4 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); DIRECT, EACH ANTISERUM" 3028688001_1 CDM 302 RC 86880 HCPCS outpatient 92 69 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 87.4 95 999999999 71.76 87.4 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); DIRECT, EACH ANTISERUM" 3028688001_1 CDM 302 RC 86880 HCPCS outpatient 92 69 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 87.4 95 999999999 71.76 87.4 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); DIRECT, EACH ANTISERUM" 3028688001_1 CDM 302 RC 86880 HCPCS outpatient 92 69 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 81.88 89 999999999 71.76 87.4 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); DIRECT, EACH ANTISERUM" 3028688001_1 CDM 302 RC 86880 HCPCS outpatient 92 69 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 80.96 88 999999999 71.76 87.4 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); DIRECT, EACH ANTISERUM" 3028688001_1 CDM 302 RC 86880 HCPCS outpatient 92 69 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 81.88 89 999999999 71.76 87.4 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); INDIRECT, QUALITATIVE, EACH REAGENT RED CELL" 3028688501_1 CDM 302 RC 86885 HCPCS outpatient 98 73.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 88.2 90 999999999 76.44 93.1 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); INDIRECT, QUALITATIVE, EACH REAGENT RED CELL" 3028688501_1 CDM 302 RC 86885 HCPCS outpatient 98 73.5 AETNA MCR ADV AETNA MCR ADV 76.44 78 999999999 76.44 93.1 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); INDIRECT, QUALITATIVE, EACH REAGENT RED CELL" 3028688501_1 CDM 302 RC 86885 HCPCS outpatient 98 73.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 85.82 87.57 999999999 76.44 93.1 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); INDIRECT, QUALITATIVE, EACH REAGENT RED CELL" 3028688501_1 CDM 302 RC 86885 HCPCS outpatient 98 73.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 83.37 85.07 999999999 76.44 93.1 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); INDIRECT, QUALITATIVE, EACH REAGENT RED CELL" 3028688501_1 CDM 302 RC 86885 HCPCS outpatient 98 73.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 83.37 85.07 999999999 76.44 93.1 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); INDIRECT, QUALITATIVE, EACH REAGENT RED CELL" 3028688501_1 CDM 302 RC 86885 HCPCS outpatient 98 73.5 MOLINA MCAID MOLINA MCAID 81.73 83.4 999999999 76.44 93.1 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); INDIRECT, QUALITATIVE, EACH REAGENT RED CELL" 3028688501_1 CDM 302 RC 86885 HCPCS outpatient 98 73.5 MOLINA MCR ADV MOLINA MCR ADV 87.22 89 999999999 76.44 93.1 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); INDIRECT, QUALITATIVE, EACH REAGENT RED CELL" 3028688501_1 CDM 302 RC 86885 HCPCS outpatient 98 73.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 87.22 89 999999999 76.44 93.1 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); INDIRECT, QUALITATIVE, EACH REAGENT RED CELL" 3028688501_1 CDM 302 RC 86885 HCPCS outpatient 98 73.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 87.22 89 999999999 76.44 93.1 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); INDIRECT, QUALITATIVE, EACH REAGENT RED CELL" 3028688501_1 CDM 302 RC 86885 HCPCS outpatient 98 73.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 88.2 90 999999999 76.44 93.1 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); INDIRECT, QUALITATIVE, EACH REAGENT RED CELL" 3028688501_1 CDM 302 RC 86885 HCPCS outpatient 98 73.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 93.1 95 999999999 76.44 93.1 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); INDIRECT, QUALITATIVE, EACH REAGENT RED CELL" 3028688501_1 CDM 302 RC 86885 HCPCS outpatient 98 73.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 93.1 95 999999999 76.44 93.1 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); INDIRECT, QUALITATIVE, EACH REAGENT RED CELL" 3028688501_1 CDM 302 RC 86885 HCPCS outpatient 98 73.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 87.22 89 999999999 76.44 93.1 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); INDIRECT, QUALITATIVE, EACH REAGENT RED CELL" 3028688501_1 CDM 302 RC 86885 HCPCS outpatient 98 73.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 86.24 88 999999999 76.44 93.1 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); INDIRECT, QUALITATIVE, EACH REAGENT RED CELL" 3028688501_1 CDM 302 RC 86885 HCPCS outpatient 98 73.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 87.22 89 999999999 76.44 93.1 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); INDIRECT, EACH ANTIBODY TITER" 3028688601_1 CDM 302 RC 86886 HCPCS outpatient 65 48.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 58.5 90 999999999 50.7 61.75 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); INDIRECT, EACH ANTIBODY TITER" 3028688601_1 CDM 302 RC 86886 HCPCS outpatient 65 48.75 AETNA MCR ADV AETNA MCR ADV 50.7 78 999999999 50.7 61.75 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); INDIRECT, EACH ANTIBODY TITER" 3028688601_1 CDM 302 RC 86886 HCPCS outpatient 65 48.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 56.92 87.57 999999999 50.7 61.75 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); INDIRECT, EACH ANTIBODY TITER" 3028688601_1 CDM 302 RC 86886 HCPCS outpatient 65 48.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 55.3 85.07 999999999 50.7 61.75 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); INDIRECT, EACH ANTIBODY TITER" 3028688601_1 CDM 302 RC 86886 HCPCS outpatient 65 48.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 55.3 85.07 999999999 50.7 61.75 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); INDIRECT, EACH ANTIBODY TITER" 3028688601_1 CDM 302 RC 86886 HCPCS outpatient 65 48.75 MOLINA MCAID MOLINA MCAID 54.21 83.4 999999999 50.7 61.75 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); INDIRECT, EACH ANTIBODY TITER" 3028688601_1 CDM 302 RC 86886 HCPCS outpatient 65 48.75 MOLINA MCR ADV MOLINA MCR ADV 57.85 89 999999999 50.7 61.75 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); INDIRECT, EACH ANTIBODY TITER" 3028688601_1 CDM 302 RC 86886 HCPCS outpatient 65 48.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 57.85 89 999999999 50.7 61.75 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); INDIRECT, EACH ANTIBODY TITER" 3028688601_1 CDM 302 RC 86886 HCPCS outpatient 65 48.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 57.85 89 999999999 50.7 61.75 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); INDIRECT, EACH ANTIBODY TITER" 3028688601_1 CDM 302 RC 86886 HCPCS outpatient 65 48.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 58.5 90 999999999 50.7 61.75 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); INDIRECT, EACH ANTIBODY TITER" 3028688601_1 CDM 302 RC 86886 HCPCS outpatient 65 48.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 61.75 95 999999999 50.7 61.75 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); INDIRECT, EACH ANTIBODY TITER" 3028688601_1 CDM 302 RC 86886 HCPCS outpatient 65 48.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 61.75 95 999999999 50.7 61.75 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); INDIRECT, EACH ANTIBODY TITER" 3028688601_1 CDM 302 RC 86886 HCPCS outpatient 65 48.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 57.85 89 999999999 50.7 61.75 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); INDIRECT, EACH ANTIBODY TITER" 3028688601_1 CDM 302 RC 86886 HCPCS outpatient 65 48.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 57.2 88 999999999 50.7 61.75 percent of total billed charges "ANTIHUMAN GLOBULIN TEST (COOMBS TEST); INDIRECT, EACH ANTIBODY TITER" 3028688601_1 CDM 302 RC 86886 HCPCS outpatient 65 48.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 57.85 89 999999999 50.7 61.75 percent of total billed charges "BLOOD TYPING, SEROLOGIC; ABO" 3028690001_1 CDM 302 RC 86900 HCPCS outpatient 58 43.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 52.2 90 999999999 45.24 55.1 percent of total billed charges "BLOOD TYPING, SEROLOGIC; ABO" 3028690001_1 CDM 302 RC 86900 HCPCS outpatient 58 43.5 AETNA MCR ADV AETNA MCR ADV 45.24 78 999999999 45.24 55.1 percent of total billed charges "BLOOD TYPING, SEROLOGIC; ABO" 3028690001_1 CDM 302 RC 86900 HCPCS outpatient 58 43.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50.79 87.57 999999999 45.24 55.1 percent of total billed charges "BLOOD TYPING, SEROLOGIC; ABO" 3028690001_1 CDM 302 RC 86900 HCPCS outpatient 58 43.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 49.34 85.07 999999999 45.24 55.1 percent of total billed charges "BLOOD TYPING, SEROLOGIC; ABO" 3028690001_1 CDM 302 RC 86900 HCPCS outpatient 58 43.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 49.34 85.07 999999999 45.24 55.1 percent of total billed charges "BLOOD TYPING, SEROLOGIC; ABO" 3028690001_1 CDM 302 RC 86900 HCPCS outpatient 58 43.5 MOLINA MCAID MOLINA MCAID 48.37 83.4 999999999 45.24 55.1 percent of total billed charges "BLOOD TYPING, SEROLOGIC; ABO" 3028690001_1 CDM 302 RC 86900 HCPCS outpatient 58 43.5 MOLINA MCR ADV MOLINA MCR ADV 51.62 89 999999999 45.24 55.1 percent of total billed charges "BLOOD TYPING, SEROLOGIC; ABO" 3028690001_1 CDM 302 RC 86900 HCPCS outpatient 58 43.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 51.62 89 999999999 45.24 55.1 percent of total billed charges "BLOOD TYPING, SEROLOGIC; ABO" 3028690001_1 CDM 302 RC 86900 HCPCS outpatient 58 43.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 51.62 89 999999999 45.24 55.1 percent of total billed charges "BLOOD TYPING, SEROLOGIC; ABO" 3028690001_1 CDM 302 RC 86900 HCPCS outpatient 58 43.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 52.2 90 999999999 45.24 55.1 percent of total billed charges "BLOOD TYPING, SEROLOGIC; ABO" 3028690001_1 CDM 302 RC 86900 HCPCS outpatient 58 43.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 55.1 95 999999999 45.24 55.1 percent of total billed charges "BLOOD TYPING, SEROLOGIC; ABO" 3028690001_1 CDM 302 RC 86900 HCPCS outpatient 58 43.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 55.1 95 999999999 45.24 55.1 percent of total billed charges "BLOOD TYPING, SEROLOGIC; ABO" 3028690001_1 CDM 302 RC 86900 HCPCS outpatient 58 43.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 51.62 89 999999999 45.24 55.1 percent of total billed charges "BLOOD TYPING, SEROLOGIC; ABO" 3028690001_1 CDM 302 RC 86900 HCPCS outpatient 58 43.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 51.04 88 999999999 45.24 55.1 percent of total billed charges "BLOOD TYPING, SEROLOGIC; ABO" 3028690001_1 CDM 302 RC 86900 HCPCS outpatient 58 43.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 51.62 89 999999999 45.24 55.1 percent of total billed charges "BLOOD TYPING, SEROLOGIC; RH (D)" 3028690101_1 CDM 302 RC 86901 HCPCS outpatient 47 35.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 42.3 90 999999999 36.66 44.65 percent of total billed charges "BLOOD TYPING, SEROLOGIC; RH (D)" 3028690101_1 CDM 302 RC 86901 HCPCS outpatient 47 35.25 AETNA MCR ADV AETNA MCR ADV 36.66 78 999999999 36.66 44.65 percent of total billed charges "BLOOD TYPING, SEROLOGIC; RH (D)" 3028690101_1 CDM 302 RC 86901 HCPCS outpatient 47 35.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 41.16 87.57 999999999 36.66 44.65 percent of total billed charges "BLOOD TYPING, SEROLOGIC; RH (D)" 3028690101_1 CDM 302 RC 86901 HCPCS outpatient 47 35.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 39.98 85.07 999999999 36.66 44.65 percent of total billed charges "BLOOD TYPING, SEROLOGIC; RH (D)" 3028690101_1 CDM 302 RC 86901 HCPCS outpatient 47 35.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 39.98 85.07 999999999 36.66 44.65 percent of total billed charges "BLOOD TYPING, SEROLOGIC; RH (D)" 3028690101_1 CDM 302 RC 86901 HCPCS outpatient 47 35.25 MOLINA MCAID MOLINA MCAID 39.2 83.4 999999999 36.66 44.65 percent of total billed charges "BLOOD TYPING, SEROLOGIC; RH (D)" 3028690101_1 CDM 302 RC 86901 HCPCS outpatient 47 35.25 MOLINA MCR ADV MOLINA MCR ADV 41.83 89 999999999 36.66 44.65 percent of total billed charges "BLOOD TYPING, SEROLOGIC; RH (D)" 3028690101_1 CDM 302 RC 86901 HCPCS outpatient 47 35.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 41.83 89 999999999 36.66 44.65 percent of total billed charges "BLOOD TYPING, SEROLOGIC; RH (D)" 3028690101_1 CDM 302 RC 86901 HCPCS outpatient 47 35.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 41.83 89 999999999 36.66 44.65 percent of total billed charges "BLOOD TYPING, SEROLOGIC; RH (D)" 3028690101_1 CDM 302 RC 86901 HCPCS outpatient 47 35.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 42.3 90 999999999 36.66 44.65 percent of total billed charges "BLOOD TYPING, SEROLOGIC; RH (D)" 3028690101_1 CDM 302 RC 86901 HCPCS outpatient 47 35.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 44.65 95 999999999 36.66 44.65 percent of total billed charges "BLOOD TYPING, SEROLOGIC; RH (D)" 3028690101_1 CDM 302 RC 86901 HCPCS outpatient 47 35.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 44.65 95 999999999 36.66 44.65 percent of total billed charges "BLOOD TYPING, SEROLOGIC; RH (D)" 3028690101_1 CDM 302 RC 86901 HCPCS outpatient 47 35.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 41.83 89 999999999 36.66 44.65 percent of total billed charges "BLOOD TYPING, SEROLOGIC; RH (D)" 3028690101_1 CDM 302 RC 86901 HCPCS outpatient 47 35.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 41.36 88 999999999 36.66 44.65 percent of total billed charges "BLOOD TYPING, SEROLOGIC; RH (D)" 3028690101_1 CDM 302 RC 86901 HCPCS outpatient 47 35.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 41.83 89 999999999 36.66 44.65 percent of total billed charges COMPATIBILITY TEST EACH UNIT; IMMEDIATE SPIN TECHNIQUE 3028692001_1 CDM 302 RC 86920 HCPCS outpatient 155 116.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 139.5 90 999999999 120.9 147.25 percent of total billed charges COMPATIBILITY TEST EACH UNIT; IMMEDIATE SPIN TECHNIQUE 3028692001_1 CDM 302 RC 86920 HCPCS outpatient 155 116.25 AETNA MCR ADV AETNA MCR ADV 120.9 78 999999999 120.9 147.25 percent of total billed charges COMPATIBILITY TEST EACH UNIT; IMMEDIATE SPIN TECHNIQUE 3028692001_1 CDM 302 RC 86920 HCPCS outpatient 155 116.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 135.73 87.57 999999999 120.9 147.25 percent of total billed charges COMPATIBILITY TEST EACH UNIT; IMMEDIATE SPIN TECHNIQUE 3028692001_1 CDM 302 RC 86920 HCPCS outpatient 155 116.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 131.86 85.07 999999999 120.9 147.25 percent of total billed charges COMPATIBILITY TEST EACH UNIT; IMMEDIATE SPIN TECHNIQUE 3028692001_1 CDM 302 RC 86920 HCPCS outpatient 155 116.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 131.86 85.07 999999999 120.9 147.25 percent of total billed charges COMPATIBILITY TEST EACH UNIT; IMMEDIATE SPIN TECHNIQUE 3028692001_1 CDM 302 RC 86920 HCPCS outpatient 155 116.25 MOLINA MCAID MOLINA MCAID 129.27 83.4 999999999 120.9 147.25 percent of total billed charges COMPATIBILITY TEST EACH UNIT; IMMEDIATE SPIN TECHNIQUE 3028692001_1 CDM 302 RC 86920 HCPCS outpatient 155 116.25 MOLINA MCR ADV MOLINA MCR ADV 137.95 89 999999999 120.9 147.25 percent of total billed charges COMPATIBILITY TEST EACH UNIT; IMMEDIATE SPIN TECHNIQUE 3028692001_1 CDM 302 RC 86920 HCPCS outpatient 155 116.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 137.95 89 999999999 120.9 147.25 percent of total billed charges COMPATIBILITY TEST EACH UNIT; IMMEDIATE SPIN TECHNIQUE 3028692001_1 CDM 302 RC 86920 HCPCS outpatient 155 116.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 137.95 89 999999999 120.9 147.25 percent of total billed charges COMPATIBILITY TEST EACH UNIT; IMMEDIATE SPIN TECHNIQUE 3028692001_1 CDM 302 RC 86920 HCPCS outpatient 155 116.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 139.5 90 999999999 120.9 147.25 percent of total billed charges COMPATIBILITY TEST EACH UNIT; IMMEDIATE SPIN TECHNIQUE 3028692001_1 CDM 302 RC 86920 HCPCS outpatient 155 116.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 147.25 95 999999999 120.9 147.25 percent of total billed charges COMPATIBILITY TEST EACH UNIT; IMMEDIATE SPIN TECHNIQUE 3028692001_1 CDM 302 RC 86920 HCPCS outpatient 155 116.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 147.25 95 999999999 120.9 147.25 percent of total billed charges COMPATIBILITY TEST EACH UNIT; IMMEDIATE SPIN TECHNIQUE 3028692001_1 CDM 302 RC 86920 HCPCS outpatient 155 116.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 137.95 89 999999999 120.9 147.25 percent of total billed charges COMPATIBILITY TEST EACH UNIT; IMMEDIATE SPIN TECHNIQUE 3028692001_1 CDM 302 RC 86920 HCPCS outpatient 155 116.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 136.4 88 999999999 120.9 147.25 percent of total billed charges COMPATIBILITY TEST EACH UNIT; IMMEDIATE SPIN TECHNIQUE 3028692001_1 CDM 302 RC 86920 HCPCS outpatient 155 116.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 137.95 89 999999999 120.9 147.25 percent of total billed charges "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 30300_1 CDM 360 RC 30300 HCPCS outpatient 384 288 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 345.6 999999999 299.52 364.8 case rate "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 30300_1 CDM 360 RC 30300 HCPCS outpatient 384 288 AETNA MCR ADV AETNA MCR ADV 299.52 78 999999999 299.52 364.8 percent of total billed charges "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 30300_1 CDM 360 RC 30300 HCPCS outpatient 384 288 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 336.27 87.57 999999999 299.52 364.8 percent of total billed charges "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 30300_1 CDM 360 RC 30300 HCPCS outpatient 384 288 COORDINATED CARE MCAID COORDINATED CARE MCAID 326.67 85.07 999999999 299.52 364.8 percent of total billed charges "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 30300_1 CDM 360 RC 30300 HCPCS outpatient 384 288 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 326.67 85.07 999999999 299.52 364.8 percent of total billed charges "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 30300_1 CDM 360 RC 30300 HCPCS outpatient 384 288 MOLINA MCAID MOLINA MCAID 320.26 83.4 999999999 299.52 364.8 percent of total billed charges "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 30300_1 CDM 360 RC 30300 HCPCS outpatient 384 288 MOLINA MCR ADV MOLINA MCR ADV 341.76 89 999999999 299.52 364.8 percent of total billed charges "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 30300_1 CDM 360 RC 30300 HCPCS outpatient 384 288 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 341.76 89 999999999 299.52 364.8 percent of total billed charges "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 30300_1 CDM 360 RC 30300 HCPCS outpatient 384 288 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 341.76 89 999999999 299.52 364.8 percent of total billed charges "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 30300_1 CDM 360 RC 30300 HCPCS outpatient 384 288 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 345.6 90 999999999 299.52 364.8 percent of total billed charges "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 30300_1 CDM 360 RC 30300 HCPCS outpatient 384 288 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 364.8 95 999999999 299.52 364.8 percent of total billed charges "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 30300_1 CDM 360 RC 30300 HCPCS outpatient 384 288 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 364.8 95 999999999 299.52 364.8 percent of total billed charges "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 30300_1 CDM 360 RC 30300 HCPCS outpatient 384 288 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 341.76 89 999999999 299.52 364.8 percent of total billed charges "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 30300_1 CDM 360 RC 30300 HCPCS outpatient 384 288 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 337.92 88 999999999 299.52 364.8 percent of total billed charges "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 30300_1 CDM 360 RC 30300 HCPCS outpatient 384 288 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 341.76 89 999999999 299.52 364.8 percent of total billed charges "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 30300_3 CDM 360 RC 30300 HCPCS outpatient 441 330.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 396.9 999999999 343.98 418.95 case rate "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 30300_3 CDM 360 RC 30300 HCPCS outpatient 441 330.75 AETNA MCR ADV AETNA MCR ADV 343.98 78 999999999 343.98 418.95 percent of total billed charges "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 30300_3 CDM 360 RC 30300 HCPCS outpatient 441 330.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 386.18 87.57 999999999 343.98 418.95 percent of total billed charges "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 30300_3 CDM 360 RC 30300 HCPCS outpatient 441 330.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 375.16 85.07 999999999 343.98 418.95 percent of total billed charges "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 30300_3 CDM 360 RC 30300 HCPCS outpatient 441 330.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 375.16 85.07 999999999 343.98 418.95 percent of total billed charges "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 30300_3 CDM 360 RC 30300 HCPCS outpatient 441 330.75 MOLINA MCAID MOLINA MCAID 367.79 83.4 999999999 343.98 418.95 percent of total billed charges "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 30300_3 CDM 360 RC 30300 HCPCS outpatient 441 330.75 MOLINA MCR ADV MOLINA MCR ADV 392.49 89 999999999 343.98 418.95 percent of total billed charges "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 30300_3 CDM 360 RC 30300 HCPCS outpatient 441 330.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 392.49 89 999999999 343.98 418.95 percent of total billed charges "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 30300_3 CDM 360 RC 30300 HCPCS outpatient 441 330.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 392.49 89 999999999 343.98 418.95 percent of total billed charges "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 30300_3 CDM 360 RC 30300 HCPCS outpatient 441 330.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 396.9 90 999999999 343.98 418.95 percent of total billed charges "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 30300_3 CDM 360 RC 30300 HCPCS outpatient 441 330.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 418.95 95 999999999 343.98 418.95 percent of total billed charges "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 30300_3 CDM 360 RC 30300 HCPCS outpatient 441 330.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 418.95 95 999999999 343.98 418.95 percent of total billed charges "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 30300_3 CDM 360 RC 30300 HCPCS outpatient 441 330.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 392.49 89 999999999 343.98 418.95 percent of total billed charges "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 30300_3 CDM 360 RC 30300 HCPCS outpatient 441 330.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 388.08 88 999999999 343.98 418.95 percent of total billed charges "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 30300_3 CDM 360 RC 30300 HCPCS outpatient 441 330.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 392.49 89 999999999 343.98 418.95 percent of total billed charges "BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC EXAMINATION WITH MANUAL DIFFERENTIAL WBC COUNT" 3058500701_1 CDM 305 RC 85007 HCPCS outpatient 54 40.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 48.6 90 999999999 42.12 51.3 percent of total billed charges "BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC EXAMINATION WITH MANUAL DIFFERENTIAL WBC COUNT" 3058500701_1 CDM 305 RC 85007 HCPCS outpatient 54 40.5 AETNA MCR ADV AETNA MCR ADV 42.12 78 999999999 42.12 51.3 percent of total billed charges "BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC EXAMINATION WITH MANUAL DIFFERENTIAL WBC COUNT" 3058500701_1 CDM 305 RC 85007 HCPCS outpatient 54 40.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 47.29 87.57 999999999 42.12 51.3 percent of total billed charges "BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC EXAMINATION WITH MANUAL DIFFERENTIAL WBC COUNT" 3058500701_1 CDM 305 RC 85007 HCPCS outpatient 54 40.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 45.94 85.07 999999999 42.12 51.3 percent of total billed charges "BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC EXAMINATION WITH MANUAL DIFFERENTIAL WBC COUNT" 3058500701_1 CDM 305 RC 85007 HCPCS outpatient 54 40.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 45.94 85.07 999999999 42.12 51.3 percent of total billed charges "BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC EXAMINATION WITH MANUAL DIFFERENTIAL WBC COUNT" 3058500701_1 CDM 305 RC 85007 HCPCS outpatient 54 40.5 MOLINA MCAID MOLINA MCAID 45.04 83.4 999999999 42.12 51.3 percent of total billed charges "BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC EXAMINATION WITH MANUAL DIFFERENTIAL WBC COUNT" 3058500701_1 CDM 305 RC 85007 HCPCS outpatient 54 40.5 MOLINA MCR ADV MOLINA MCR ADV 48.06 89 999999999 42.12 51.3 percent of total billed charges "BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC EXAMINATION WITH MANUAL DIFFERENTIAL WBC COUNT" 3058500701_1 CDM 305 RC 85007 HCPCS outpatient 54 40.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 48.06 89 999999999 42.12 51.3 percent of total billed charges "BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC EXAMINATION WITH MANUAL DIFFERENTIAL WBC COUNT" 3058500701_1 CDM 305 RC 85007 HCPCS outpatient 54 40.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 48.06 89 999999999 42.12 51.3 percent of total billed charges "BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC EXAMINATION WITH MANUAL DIFFERENTIAL WBC COUNT" 3058500701_1 CDM 305 RC 85007 HCPCS outpatient 54 40.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 48.6 90 999999999 42.12 51.3 percent of total billed charges "BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC EXAMINATION WITH MANUAL DIFFERENTIAL WBC COUNT" 3058500701_1 CDM 305 RC 85007 HCPCS outpatient 54 40.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 51.3 95 999999999 42.12 51.3 percent of total billed charges "BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC EXAMINATION WITH MANUAL DIFFERENTIAL WBC COUNT" 3058500701_1 CDM 305 RC 85007 HCPCS outpatient 54 40.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 51.3 95 999999999 42.12 51.3 percent of total billed charges "BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC EXAMINATION WITH MANUAL DIFFERENTIAL WBC COUNT" 3058500701_1 CDM 305 RC 85007 HCPCS outpatient 54 40.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 48.06 89 999999999 42.12 51.3 percent of total billed charges "BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC EXAMINATION WITH MANUAL DIFFERENTIAL WBC COUNT" 3058500701_1 CDM 305 RC 85007 HCPCS outpatient 54 40.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 47.52 88 999999999 42.12 51.3 percent of total billed charges "BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC EXAMINATION WITH MANUAL DIFFERENTIAL WBC COUNT" 3058500701_1 CDM 305 RC 85007 HCPCS outpatient 54 40.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 48.06 89 999999999 42.12 51.3 percent of total billed charges BLOOD COUNT; HEMATOCRIT (HCT) 3058501403_1 CDM 305 RC 85014 HCPCS outpatient 46 34.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 41.4 90 999999999 35.88 43.7 percent of total billed charges BLOOD COUNT; HEMATOCRIT (HCT) 3058501403_1 CDM 305 RC 85014 HCPCS outpatient 46 34.5 AETNA MCR ADV AETNA MCR ADV 35.88 78 999999999 35.88 43.7 percent of total billed charges BLOOD COUNT; HEMATOCRIT (HCT) 3058501403_1 CDM 305 RC 85014 HCPCS outpatient 46 34.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 40.28 87.57 999999999 35.88 43.7 percent of total billed charges BLOOD COUNT; HEMATOCRIT (HCT) 3058501403_1 CDM 305 RC 85014 HCPCS outpatient 46 34.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 39.13 85.07 999999999 35.88 43.7 percent of total billed charges BLOOD COUNT; HEMATOCRIT (HCT) 3058501403_1 CDM 305 RC 85014 HCPCS outpatient 46 34.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 39.13 85.07 999999999 35.88 43.7 percent of total billed charges BLOOD COUNT; HEMATOCRIT (HCT) 3058501403_1 CDM 305 RC 85014 HCPCS outpatient 46 34.5 MOLINA MCAID MOLINA MCAID 38.36 83.4 999999999 35.88 43.7 percent of total billed charges BLOOD COUNT; HEMATOCRIT (HCT) 3058501403_1 CDM 305 RC 85014 HCPCS outpatient 46 34.5 MOLINA MCR ADV MOLINA MCR ADV 40.94 89 999999999 35.88 43.7 percent of total billed charges BLOOD COUNT; HEMATOCRIT (HCT) 3058501403_1 CDM 305 RC 85014 HCPCS outpatient 46 34.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 40.94 89 999999999 35.88 43.7 percent of total billed charges BLOOD COUNT; HEMATOCRIT (HCT) 3058501403_1 CDM 305 RC 85014 HCPCS outpatient 46 34.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 40.94 89 999999999 35.88 43.7 percent of total billed charges BLOOD COUNT; HEMATOCRIT (HCT) 3058501403_1 CDM 305 RC 85014 HCPCS outpatient 46 34.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 41.4 90 999999999 35.88 43.7 percent of total billed charges BLOOD COUNT; HEMATOCRIT (HCT) 3058501403_1 CDM 305 RC 85014 HCPCS outpatient 46 34.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 43.7 95 999999999 35.88 43.7 percent of total billed charges BLOOD COUNT; HEMATOCRIT (HCT) 3058501403_1 CDM 305 RC 85014 HCPCS outpatient 46 34.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 43.7 95 999999999 35.88 43.7 percent of total billed charges BLOOD COUNT; HEMATOCRIT (HCT) 3058501403_1 CDM 305 RC 85014 HCPCS outpatient 46 34.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 40.94 89 999999999 35.88 43.7 percent of total billed charges BLOOD COUNT; HEMATOCRIT (HCT) 3058501403_1 CDM 305 RC 85014 HCPCS outpatient 46 34.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 40.48 88 999999999 35.88 43.7 percent of total billed charges BLOOD COUNT; HEMATOCRIT (HCT) 3058501403_1 CDM 305 RC 85014 HCPCS outpatient 46 34.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 40.94 89 999999999 35.88 43.7 percent of total billed charges BLOOD COUNT; HEMOGLOBIN (HGB) 3058501806_1 CDM 305 RC 85018 HCPCS outpatient 42 31.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 37.8 90 999999999 32.76 39.9 percent of total billed charges BLOOD COUNT; HEMOGLOBIN (HGB) 3058501806_1 CDM 305 RC 85018 HCPCS outpatient 42 31.5 AETNA MCR ADV AETNA MCR ADV 32.76 78 999999999 32.76 39.9 percent of total billed charges BLOOD COUNT; HEMOGLOBIN (HGB) 3058501806_1 CDM 305 RC 85018 HCPCS outpatient 42 31.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 36.78 87.57 999999999 32.76 39.9 percent of total billed charges BLOOD COUNT; HEMOGLOBIN (HGB) 3058501806_1 CDM 305 RC 85018 HCPCS outpatient 42 31.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 35.73 85.07 999999999 32.76 39.9 percent of total billed charges BLOOD COUNT; HEMOGLOBIN (HGB) 3058501806_1 CDM 305 RC 85018 HCPCS outpatient 42 31.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 35.73 85.07 999999999 32.76 39.9 percent of total billed charges BLOOD COUNT; HEMOGLOBIN (HGB) 3058501806_1 CDM 305 RC 85018 HCPCS outpatient 42 31.5 MOLINA MCAID MOLINA MCAID 35.03 83.4 999999999 32.76 39.9 percent of total billed charges BLOOD COUNT; HEMOGLOBIN (HGB) 3058501806_1 CDM 305 RC 85018 HCPCS outpatient 42 31.5 MOLINA MCR ADV MOLINA MCR ADV 37.38 89 999999999 32.76 39.9 percent of total billed charges BLOOD COUNT; HEMOGLOBIN (HGB) 3058501806_1 CDM 305 RC 85018 HCPCS outpatient 42 31.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 37.38 89 999999999 32.76 39.9 percent of total billed charges BLOOD COUNT; HEMOGLOBIN (HGB) 3058501806_1 CDM 305 RC 85018 HCPCS outpatient 42 31.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 37.38 89 999999999 32.76 39.9 percent of total billed charges BLOOD COUNT; HEMOGLOBIN (HGB) 3058501806_1 CDM 305 RC 85018 HCPCS outpatient 42 31.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 37.8 90 999999999 32.76 39.9 percent of total billed charges BLOOD COUNT; HEMOGLOBIN (HGB) 3058501806_1 CDM 305 RC 85018 HCPCS outpatient 42 31.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 39.9 95 999999999 32.76 39.9 percent of total billed charges BLOOD COUNT; HEMOGLOBIN (HGB) 3058501806_1 CDM 305 RC 85018 HCPCS outpatient 42 31.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 39.9 95 999999999 32.76 39.9 percent of total billed charges BLOOD COUNT; HEMOGLOBIN (HGB) 3058501806_1 CDM 305 RC 85018 HCPCS outpatient 42 31.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 37.38 89 999999999 32.76 39.9 percent of total billed charges BLOOD COUNT; HEMOGLOBIN (HGB) 3058501806_1 CDM 305 RC 85018 HCPCS outpatient 42 31.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 36.96 88 999999999 32.76 39.9 percent of total billed charges BLOOD COUNT; HEMOGLOBIN (HGB) 3058501806_1 CDM 305 RC 85018 HCPCS outpatient 42 31.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 37.38 89 999999999 32.76 39.9 percent of total billed charges "BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND PLATELET COUNT) AND AUTOMATED DIFFERENTIAL WBC COUNT" 3058502501_1 CDM 305 RC 85025 HCPCS outpatient 96 72 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 86.4 90 999999999 74.88 91.2 percent of total billed charges "BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND PLATELET COUNT) AND AUTOMATED DIFFERENTIAL WBC COUNT" 3058502501_1 CDM 305 RC 85025 HCPCS outpatient 96 72 AETNA MCR ADV AETNA MCR ADV 74.88 78 999999999 74.88 91.2 percent of total billed charges "BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND PLATELET COUNT) AND AUTOMATED DIFFERENTIAL WBC COUNT" 3058502501_1 CDM 305 RC 85025 HCPCS outpatient 96 72 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 84.07 87.57 999999999 74.88 91.2 percent of total billed charges "BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND PLATELET COUNT) AND AUTOMATED DIFFERENTIAL WBC COUNT" 3058502501_1 CDM 305 RC 85025 HCPCS outpatient 96 72 COORDINATED CARE MCAID COORDINATED CARE MCAID 81.67 85.07 999999999 74.88 91.2 percent of total billed charges "BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND PLATELET COUNT) AND AUTOMATED DIFFERENTIAL WBC COUNT" 3058502501_1 CDM 305 RC 85025 HCPCS outpatient 96 72 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 81.67 85.07 999999999 74.88 91.2 percent of total billed charges "BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND PLATELET COUNT) AND AUTOMATED DIFFERENTIAL WBC COUNT" 3058502501_1 CDM 305 RC 85025 HCPCS outpatient 96 72 MOLINA MCAID MOLINA MCAID 80.06 83.4 999999999 74.88 91.2 percent of total billed charges "BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND PLATELET COUNT) AND AUTOMATED DIFFERENTIAL WBC COUNT" 3058502501_1 CDM 305 RC 85025 HCPCS outpatient 96 72 MOLINA MCR ADV MOLINA MCR ADV 85.44 89 999999999 74.88 91.2 percent of total billed charges "BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND PLATELET COUNT) AND AUTOMATED DIFFERENTIAL WBC COUNT" 3058502501_1 CDM 305 RC 85025 HCPCS outpatient 96 72 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 85.44 89 999999999 74.88 91.2 percent of total billed charges "BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND PLATELET COUNT) AND AUTOMATED DIFFERENTIAL WBC COUNT" 3058502501_1 CDM 305 RC 85025 HCPCS outpatient 96 72 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 85.44 89 999999999 74.88 91.2 percent of total billed charges "BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND PLATELET COUNT) AND AUTOMATED DIFFERENTIAL WBC COUNT" 3058502501_1 CDM 305 RC 85025 HCPCS outpatient 96 72 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 86.4 90 999999999 74.88 91.2 percent of total billed charges "BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND PLATELET COUNT) AND AUTOMATED DIFFERENTIAL WBC COUNT" 3058502501_1 CDM 305 RC 85025 HCPCS outpatient 96 72 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 91.2 95 999999999 74.88 91.2 percent of total billed charges "BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND PLATELET COUNT) AND AUTOMATED DIFFERENTIAL WBC COUNT" 3058502501_1 CDM 305 RC 85025 HCPCS outpatient 96 72 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 91.2 95 999999999 74.88 91.2 percent of total billed charges "BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND PLATELET COUNT) AND AUTOMATED DIFFERENTIAL WBC COUNT" 3058502501_1 CDM 305 RC 85025 HCPCS outpatient 96 72 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 85.44 89 999999999 74.88 91.2 percent of total billed charges "BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND PLATELET COUNT) AND AUTOMATED DIFFERENTIAL WBC COUNT" 3058502501_1 CDM 305 RC 85025 HCPCS outpatient 96 72 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 84.48 88 999999999 74.88 91.2 percent of total billed charges "BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND PLATELET COUNT) AND AUTOMATED DIFFERENTIAL WBC COUNT" 3058502501_1 CDM 305 RC 85025 HCPCS outpatient 96 72 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 85.44 89 999999999 74.88 91.2 percent of total billed charges "BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND PLATELET COUNT)" 3058502702_1 CDM 305 RC 85027 HCPCS outpatient 78 58.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 70.2 90 999999999 60.84 74.1 percent of total billed charges "BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND PLATELET COUNT)" 3058502702_1 CDM 305 RC 85027 HCPCS outpatient 78 58.5 AETNA MCR ADV AETNA MCR ADV 60.84 78 999999999 60.84 74.1 percent of total billed charges "BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND PLATELET COUNT)" 3058502702_1 CDM 305 RC 85027 HCPCS outpatient 78 58.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 68.3 87.57 999999999 60.84 74.1 percent of total billed charges "BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND PLATELET COUNT)" 3058502702_1 CDM 305 RC 85027 HCPCS outpatient 78 58.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 66.35 85.07 999999999 60.84 74.1 percent of total billed charges "BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND PLATELET COUNT)" 3058502702_1 CDM 305 RC 85027 HCPCS outpatient 78 58.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 66.35 85.07 999999999 60.84 74.1 percent of total billed charges "BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND PLATELET COUNT)" 3058502702_1 CDM 305 RC 85027 HCPCS outpatient 78 58.5 MOLINA MCAID MOLINA MCAID 65.05 83.4 999999999 60.84 74.1 percent of total billed charges "BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND PLATELET COUNT)" 3058502702_1 CDM 305 RC 85027 HCPCS outpatient 78 58.5 MOLINA MCR ADV MOLINA MCR ADV 69.42 89 999999999 60.84 74.1 percent of total billed charges "BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND PLATELET COUNT)" 3058502702_1 CDM 305 RC 85027 HCPCS outpatient 78 58.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 69.42 89 999999999 60.84 74.1 percent of total billed charges "BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND PLATELET COUNT)" 3058502702_1 CDM 305 RC 85027 HCPCS outpatient 78 58.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 69.42 89 999999999 60.84 74.1 percent of total billed charges "BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND PLATELET COUNT)" 3058502702_1 CDM 305 RC 85027 HCPCS outpatient 78 58.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 70.2 90 999999999 60.84 74.1 percent of total billed charges "BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND PLATELET COUNT)" 3058502702_1 CDM 305 RC 85027 HCPCS outpatient 78 58.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 74.1 95 999999999 60.84 74.1 percent of total billed charges "BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND PLATELET COUNT)" 3058502702_1 CDM 305 RC 85027 HCPCS outpatient 78 58.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 74.1 95 999999999 60.84 74.1 percent of total billed charges "BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND PLATELET COUNT)" 3058502702_1 CDM 305 RC 85027 HCPCS outpatient 78 58.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 69.42 89 999999999 60.84 74.1 percent of total billed charges "BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND PLATELET COUNT)" 3058502702_1 CDM 305 RC 85027 HCPCS outpatient 78 58.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 68.64 88 999999999 60.84 74.1 percent of total billed charges "BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND PLATELET COUNT)" 3058502702_1 CDM 305 RC 85027 HCPCS outpatient 78 58.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 69.42 89 999999999 60.84 74.1 percent of total billed charges "BLOOD COUNT; RED BLOOD CELL (RBC), AUTOMATED" 3058504101_1 CDM 305 RC 85041 HCPCS outpatient 48 36 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 43.2 90 999999999 37.44 45.6 percent of total billed charges "BLOOD COUNT; RED BLOOD CELL (RBC), AUTOMATED" 3058504101_1 CDM 305 RC 85041 HCPCS outpatient 48 36 AETNA MCR ADV AETNA MCR ADV 37.44 78 999999999 37.44 45.6 percent of total billed charges "BLOOD COUNT; RED BLOOD CELL (RBC), AUTOMATED" 3058504101_1 CDM 305 RC 85041 HCPCS outpatient 48 36 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 42.03 87.57 999999999 37.44 45.6 percent of total billed charges "BLOOD COUNT; RED BLOOD CELL (RBC), AUTOMATED" 3058504101_1 CDM 305 RC 85041 HCPCS outpatient 48 36 COORDINATED CARE MCAID COORDINATED CARE MCAID 40.83 85.07 999999999 37.44 45.6 percent of total billed charges "BLOOD COUNT; RED BLOOD CELL (RBC), AUTOMATED" 3058504101_1 CDM 305 RC 85041 HCPCS outpatient 48 36 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 40.83 85.07 999999999 37.44 45.6 percent of total billed charges "BLOOD COUNT; RED BLOOD CELL (RBC), AUTOMATED" 3058504101_1 CDM 305 RC 85041 HCPCS outpatient 48 36 MOLINA MCAID MOLINA MCAID 40.03 83.4 999999999 37.44 45.6 percent of total billed charges "BLOOD COUNT; RED BLOOD CELL (RBC), AUTOMATED" 3058504101_1 CDM 305 RC 85041 HCPCS outpatient 48 36 MOLINA MCR ADV MOLINA MCR ADV 42.72 89 999999999 37.44 45.6 percent of total billed charges "BLOOD COUNT; RED BLOOD CELL (RBC), AUTOMATED" 3058504101_1 CDM 305 RC 85041 HCPCS outpatient 48 36 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 42.72 89 999999999 37.44 45.6 percent of total billed charges "BLOOD COUNT; RED BLOOD CELL (RBC), AUTOMATED" 3058504101_1 CDM 305 RC 85041 HCPCS outpatient 48 36 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 42.72 89 999999999 37.44 45.6 percent of total billed charges "BLOOD COUNT; RED BLOOD CELL (RBC), AUTOMATED" 3058504101_1 CDM 305 RC 85041 HCPCS outpatient 48 36 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 43.2 90 999999999 37.44 45.6 percent of total billed charges "BLOOD COUNT; RED BLOOD CELL (RBC), AUTOMATED" 3058504101_1 CDM 305 RC 85041 HCPCS outpatient 48 36 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 45.6 95 999999999 37.44 45.6 percent of total billed charges "BLOOD COUNT; RED BLOOD CELL (RBC), AUTOMATED" 3058504101_1 CDM 305 RC 85041 HCPCS outpatient 48 36 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 45.6 95 999999999 37.44 45.6 percent of total billed charges "BLOOD COUNT; RED BLOOD CELL (RBC), AUTOMATED" 3058504101_1 CDM 305 RC 85041 HCPCS outpatient 48 36 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 42.72 89 999999999 37.44 45.6 percent of total billed charges "BLOOD COUNT; RED BLOOD CELL (RBC), AUTOMATED" 3058504101_1 CDM 305 RC 85041 HCPCS outpatient 48 36 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 42.24 88 999999999 37.44 45.6 percent of total billed charges "BLOOD COUNT; RED BLOOD CELL (RBC), AUTOMATED" 3058504101_1 CDM 305 RC 85041 HCPCS outpatient 48 36 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 42.72 89 999999999 37.44 45.6 percent of total billed charges "BLOOD COUNT; RETICULOCYTE, AUTOMATED" 3058504501_1 CDM 305 RC 85045 HCPCS outpatient 63 47.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 56.7 90 999999999 49.14 59.85 percent of total billed charges "BLOOD COUNT; RETICULOCYTE, AUTOMATED" 3058504501_1 CDM 305 RC 85045 HCPCS outpatient 63 47.25 AETNA MCR ADV AETNA MCR ADV 49.14 78 999999999 49.14 59.85 percent of total billed charges "BLOOD COUNT; RETICULOCYTE, AUTOMATED" 3058504501_1 CDM 305 RC 85045 HCPCS outpatient 63 47.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 55.17 87.57 999999999 49.14 59.85 percent of total billed charges "BLOOD COUNT; RETICULOCYTE, AUTOMATED" 3058504501_1 CDM 305 RC 85045 HCPCS outpatient 63 47.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 53.59 85.07 999999999 49.14 59.85 percent of total billed charges "BLOOD COUNT; RETICULOCYTE, AUTOMATED" 3058504501_1 CDM 305 RC 85045 HCPCS outpatient 63 47.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 53.59 85.07 999999999 49.14 59.85 percent of total billed charges "BLOOD COUNT; RETICULOCYTE, AUTOMATED" 3058504501_1 CDM 305 RC 85045 HCPCS outpatient 63 47.25 MOLINA MCAID MOLINA MCAID 52.54 83.4 999999999 49.14 59.85 percent of total billed charges "BLOOD COUNT; RETICULOCYTE, AUTOMATED" 3058504501_1 CDM 305 RC 85045 HCPCS outpatient 63 47.25 MOLINA MCR ADV MOLINA MCR ADV 56.07 89 999999999 49.14 59.85 percent of total billed charges "BLOOD COUNT; RETICULOCYTE, AUTOMATED" 3058504501_1 CDM 305 RC 85045 HCPCS outpatient 63 47.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 56.07 89 999999999 49.14 59.85 percent of total billed charges "BLOOD COUNT; RETICULOCYTE, AUTOMATED" 3058504501_1 CDM 305 RC 85045 HCPCS outpatient 63 47.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 56.07 89 999999999 49.14 59.85 percent of total billed charges "BLOOD COUNT; RETICULOCYTE, AUTOMATED" 3058504501_1 CDM 305 RC 85045 HCPCS outpatient 63 47.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 56.7 90 999999999 49.14 59.85 percent of total billed charges "BLOOD COUNT; RETICULOCYTE, AUTOMATED" 3058504501_1 CDM 305 RC 85045 HCPCS outpatient 63 47.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 59.85 95 999999999 49.14 59.85 percent of total billed charges "BLOOD COUNT; RETICULOCYTE, AUTOMATED" 3058504501_1 CDM 305 RC 85045 HCPCS outpatient 63 47.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 59.85 95 999999999 49.14 59.85 percent of total billed charges "BLOOD COUNT; RETICULOCYTE, AUTOMATED" 3058504501_1 CDM 305 RC 85045 HCPCS outpatient 63 47.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 56.07 89 999999999 49.14 59.85 percent of total billed charges "BLOOD COUNT; RETICULOCYTE, AUTOMATED" 3058504501_1 CDM 305 RC 85045 HCPCS outpatient 63 47.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 55.44 88 999999999 49.14 59.85 percent of total billed charges "BLOOD COUNT; RETICULOCYTE, AUTOMATED" 3058504501_1 CDM 305 RC 85045 HCPCS outpatient 63 47.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 56.07 89 999999999 49.14 59.85 percent of total billed charges "BLOOD COUNT; RETICULOCYTES, AUTOMATED, INCLUDING 1 OR MORE CELLULAR PARAMETERS (EG, RETICULOCYTE HEMOGLOBIN CONTENT [CHR], IMMATURE RETICULOCYTE FRACTION [IRF], RETICULOCYTE VOLUME [MRV], RNA CONTENT), DIRECT MEASUREMENT" 3058504601_1 CDM 305 RC 85046 HCPCS outpatient 59 44.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 53.1 90 999999999 46.02 56.05 percent of total billed charges "BLOOD COUNT; RETICULOCYTES, AUTOMATED, INCLUDING 1 OR MORE CELLULAR PARAMETERS (EG, RETICULOCYTE HEMOGLOBIN CONTENT [CHR], IMMATURE RETICULOCYTE FRACTION [IRF], RETICULOCYTE VOLUME [MRV], RNA CONTENT), DIRECT MEASUREMENT" 3058504601_1 CDM 305 RC 85046 HCPCS outpatient 59 44.25 AETNA MCR ADV AETNA MCR ADV 46.02 78 999999999 46.02 56.05 percent of total billed charges "BLOOD COUNT; RETICULOCYTES, AUTOMATED, INCLUDING 1 OR MORE CELLULAR PARAMETERS (EG, RETICULOCYTE HEMOGLOBIN CONTENT [CHR], IMMATURE RETICULOCYTE FRACTION [IRF], RETICULOCYTE VOLUME [MRV], RNA CONTENT), DIRECT MEASUREMENT" 3058504601_1 CDM 305 RC 85046 HCPCS outpatient 59 44.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 51.67 87.57 999999999 46.02 56.05 percent of total billed charges "BLOOD COUNT; RETICULOCYTES, AUTOMATED, INCLUDING 1 OR MORE CELLULAR PARAMETERS (EG, RETICULOCYTE HEMOGLOBIN CONTENT [CHR], IMMATURE RETICULOCYTE FRACTION [IRF], RETICULOCYTE VOLUME [MRV], RNA CONTENT), DIRECT MEASUREMENT" 3058504601_1 CDM 305 RC 85046 HCPCS outpatient 59 44.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 50.19 85.07 999999999 46.02 56.05 percent of total billed charges "BLOOD COUNT; RETICULOCYTES, AUTOMATED, INCLUDING 1 OR MORE CELLULAR PARAMETERS (EG, RETICULOCYTE HEMOGLOBIN CONTENT [CHR], IMMATURE RETICULOCYTE FRACTION [IRF], RETICULOCYTE VOLUME [MRV], RNA CONTENT), DIRECT MEASUREMENT" 3058504601_1 CDM 305 RC 85046 HCPCS outpatient 59 44.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50.19 85.07 999999999 46.02 56.05 percent of total billed charges "BLOOD COUNT; RETICULOCYTES, AUTOMATED, INCLUDING 1 OR MORE CELLULAR PARAMETERS (EG, RETICULOCYTE HEMOGLOBIN CONTENT [CHR], IMMATURE RETICULOCYTE FRACTION [IRF], RETICULOCYTE VOLUME [MRV], RNA CONTENT), DIRECT MEASUREMENT" 3058504601_1 CDM 305 RC 85046 HCPCS outpatient 59 44.25 MOLINA MCAID MOLINA MCAID 49.21 83.4 999999999 46.02 56.05 percent of total billed charges "BLOOD COUNT; RETICULOCYTES, AUTOMATED, INCLUDING 1 OR MORE CELLULAR PARAMETERS (EG, RETICULOCYTE HEMOGLOBIN CONTENT [CHR], IMMATURE RETICULOCYTE FRACTION [IRF], RETICULOCYTE VOLUME [MRV], RNA CONTENT), DIRECT MEASUREMENT" 3058504601_1 CDM 305 RC 85046 HCPCS outpatient 59 44.25 MOLINA MCR ADV MOLINA MCR ADV 52.51 89 999999999 46.02 56.05 percent of total billed charges "BLOOD COUNT; RETICULOCYTES, AUTOMATED, INCLUDING 1 OR MORE CELLULAR PARAMETERS (EG, RETICULOCYTE HEMOGLOBIN CONTENT [CHR], IMMATURE RETICULOCYTE FRACTION [IRF], RETICULOCYTE VOLUME [MRV], RNA CONTENT), DIRECT MEASUREMENT" 3058504601_1 CDM 305 RC 85046 HCPCS outpatient 59 44.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 52.51 89 999999999 46.02 56.05 percent of total billed charges "BLOOD COUNT; RETICULOCYTES, AUTOMATED, INCLUDING 1 OR MORE CELLULAR PARAMETERS (EG, RETICULOCYTE HEMOGLOBIN CONTENT [CHR], IMMATURE RETICULOCYTE FRACTION [IRF], RETICULOCYTE VOLUME [MRV], RNA CONTENT), DIRECT MEASUREMENT" 3058504601_1 CDM 305 RC 85046 HCPCS outpatient 59 44.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 52.51 89 999999999 46.02 56.05 percent of total billed charges "BLOOD COUNT; RETICULOCYTES, AUTOMATED, INCLUDING 1 OR MORE CELLULAR PARAMETERS (EG, RETICULOCYTE HEMOGLOBIN CONTENT [CHR], IMMATURE RETICULOCYTE FRACTION [IRF], RETICULOCYTE VOLUME [MRV], RNA CONTENT), DIRECT MEASUREMENT" 3058504601_1 CDM 305 RC 85046 HCPCS outpatient 59 44.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 53.1 90 999999999 46.02 56.05 percent of total billed charges "BLOOD COUNT; RETICULOCYTES, AUTOMATED, INCLUDING 1 OR MORE CELLULAR PARAMETERS (EG, RETICULOCYTE HEMOGLOBIN CONTENT [CHR], IMMATURE RETICULOCYTE FRACTION [IRF], RETICULOCYTE VOLUME [MRV], RNA CONTENT), DIRECT MEASUREMENT" 3058504601_1 CDM 305 RC 85046 HCPCS outpatient 59 44.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 56.05 95 999999999 46.02 56.05 percent of total billed charges "BLOOD COUNT; RETICULOCYTES, AUTOMATED, INCLUDING 1 OR MORE CELLULAR PARAMETERS (EG, RETICULOCYTE HEMOGLOBIN CONTENT [CHR], IMMATURE RETICULOCYTE FRACTION [IRF], RETICULOCYTE VOLUME [MRV], RNA CONTENT), DIRECT MEASUREMENT" 3058504601_1 CDM 305 RC 85046 HCPCS outpatient 59 44.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 56.05 95 999999999 46.02 56.05 percent of total billed charges "BLOOD COUNT; RETICULOCYTES, AUTOMATED, INCLUDING 1 OR MORE CELLULAR PARAMETERS (EG, RETICULOCYTE HEMOGLOBIN CONTENT [CHR], IMMATURE RETICULOCYTE FRACTION [IRF], RETICULOCYTE VOLUME [MRV], RNA CONTENT), DIRECT MEASUREMENT" 3058504601_1 CDM 305 RC 85046 HCPCS outpatient 59 44.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 52.51 89 999999999 46.02 56.05 percent of total billed charges "BLOOD COUNT; RETICULOCYTES, AUTOMATED, INCLUDING 1 OR MORE CELLULAR PARAMETERS (EG, RETICULOCYTE HEMOGLOBIN CONTENT [CHR], IMMATURE RETICULOCYTE FRACTION [IRF], RETICULOCYTE VOLUME [MRV], RNA CONTENT), DIRECT MEASUREMENT" 3058504601_1 CDM 305 RC 85046 HCPCS outpatient 59 44.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 51.92 88 999999999 46.02 56.05 percent of total billed charges "BLOOD COUNT; RETICULOCYTES, AUTOMATED, INCLUDING 1 OR MORE CELLULAR PARAMETERS (EG, RETICULOCYTE HEMOGLOBIN CONTENT [CHR], IMMATURE RETICULOCYTE FRACTION [IRF], RETICULOCYTE VOLUME [MRV], RNA CONTENT), DIRECT MEASUREMENT" 3058504601_1 CDM 305 RC 85046 HCPCS outpatient 59 44.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 52.51 89 999999999 46.02 56.05 percent of total billed charges "BLOOD COUNT; PLATELET, AUTOMATED" 3058504901_1 CDM 305 RC 85049 HCPCS outpatient 63 47.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 56.7 90 999999999 49.14 59.85 percent of total billed charges "BLOOD COUNT; PLATELET, AUTOMATED" 3058504901_1 CDM 305 RC 85049 HCPCS outpatient 63 47.25 AETNA MCR ADV AETNA MCR ADV 49.14 78 999999999 49.14 59.85 percent of total billed charges "BLOOD COUNT; PLATELET, AUTOMATED" 3058504901_1 CDM 305 RC 85049 HCPCS outpatient 63 47.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 55.17 87.57 999999999 49.14 59.85 percent of total billed charges "BLOOD COUNT; PLATELET, AUTOMATED" 3058504901_1 CDM 305 RC 85049 HCPCS outpatient 63 47.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 53.59 85.07 999999999 49.14 59.85 percent of total billed charges "BLOOD COUNT; PLATELET, AUTOMATED" 3058504901_1 CDM 305 RC 85049 HCPCS outpatient 63 47.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 53.59 85.07 999999999 49.14 59.85 percent of total billed charges "BLOOD COUNT; PLATELET, AUTOMATED" 3058504901_1 CDM 305 RC 85049 HCPCS outpatient 63 47.25 MOLINA MCAID MOLINA MCAID 52.54 83.4 999999999 49.14 59.85 percent of total billed charges "BLOOD COUNT; PLATELET, AUTOMATED" 3058504901_1 CDM 305 RC 85049 HCPCS outpatient 63 47.25 MOLINA MCR ADV MOLINA MCR ADV 56.07 89 999999999 49.14 59.85 percent of total billed charges "BLOOD COUNT; PLATELET, AUTOMATED" 3058504901_1 CDM 305 RC 85049 HCPCS outpatient 63 47.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 56.07 89 999999999 49.14 59.85 percent of total billed charges "BLOOD COUNT; PLATELET, AUTOMATED" 3058504901_1 CDM 305 RC 85049 HCPCS outpatient 63 47.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 56.07 89 999999999 49.14 59.85 percent of total billed charges "BLOOD COUNT; PLATELET, AUTOMATED" 3058504901_1 CDM 305 RC 85049 HCPCS outpatient 63 47.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 56.7 90 999999999 49.14 59.85 percent of total billed charges "BLOOD COUNT; PLATELET, AUTOMATED" 3058504901_1 CDM 305 RC 85049 HCPCS outpatient 63 47.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 59.85 95 999999999 49.14 59.85 percent of total billed charges "BLOOD COUNT; PLATELET, AUTOMATED" 3058504901_1 CDM 305 RC 85049 HCPCS outpatient 63 47.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 59.85 95 999999999 49.14 59.85 percent of total billed charges "BLOOD COUNT; PLATELET, AUTOMATED" 3058504901_1 CDM 305 RC 85049 HCPCS outpatient 63 47.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 56.07 89 999999999 49.14 59.85 percent of total billed charges "BLOOD COUNT; PLATELET, AUTOMATED" 3058504901_1 CDM 305 RC 85049 HCPCS outpatient 63 47.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 55.44 88 999999999 49.14 59.85 percent of total billed charges "BLOOD COUNT; PLATELET, AUTOMATED" 3058504901_1 CDM 305 RC 85049 HCPCS outpatient 63 47.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 56.07 89 999999999 49.14 59.85 percent of total billed charges "BLOOD SMEAR, PERIPHERAL, INTERPRETATION BY PHYSICIAN WITH WRITTEN REPORT" 3058506001_1 CDM 305 RC 85060 HCPCS outpatient 138 103.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 124.2 90 999999999 107.64 131.1 percent of total billed charges "BLOOD SMEAR, PERIPHERAL, INTERPRETATION BY PHYSICIAN WITH WRITTEN REPORT" 3058506001_1 CDM 305 RC 85060 HCPCS outpatient 138 103.5 AETNA MCR ADV AETNA MCR ADV 107.64 78 999999999 107.64 131.1 percent of total billed charges "BLOOD SMEAR, PERIPHERAL, INTERPRETATION BY PHYSICIAN WITH WRITTEN REPORT" 3058506001_1 CDM 305 RC 85060 HCPCS outpatient 138 103.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 120.85 87.57 999999999 107.64 131.1 percent of total billed charges "BLOOD SMEAR, PERIPHERAL, INTERPRETATION BY PHYSICIAN WITH WRITTEN REPORT" 3058506001_1 CDM 305 RC 85060 HCPCS outpatient 138 103.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 117.4 85.07 999999999 107.64 131.1 percent of total billed charges "BLOOD SMEAR, PERIPHERAL, INTERPRETATION BY PHYSICIAN WITH WRITTEN REPORT" 3058506001_1 CDM 305 RC 85060 HCPCS outpatient 138 103.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 117.4 85.07 999999999 107.64 131.1 percent of total billed charges "BLOOD SMEAR, PERIPHERAL, INTERPRETATION BY PHYSICIAN WITH WRITTEN REPORT" 3058506001_1 CDM 305 RC 85060 HCPCS outpatient 138 103.5 MOLINA MCAID MOLINA MCAID 115.09 83.4 999999999 107.64 131.1 percent of total billed charges "BLOOD SMEAR, PERIPHERAL, INTERPRETATION BY PHYSICIAN WITH WRITTEN REPORT" 3058506001_1 CDM 305 RC 85060 HCPCS outpatient 138 103.5 MOLINA MCR ADV MOLINA MCR ADV 122.82 89 999999999 107.64 131.1 percent of total billed charges "BLOOD SMEAR, PERIPHERAL, INTERPRETATION BY PHYSICIAN WITH WRITTEN REPORT" 3058506001_1 CDM 305 RC 85060 HCPCS outpatient 138 103.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 122.82 89 999999999 107.64 131.1 percent of total billed charges "BLOOD SMEAR, PERIPHERAL, INTERPRETATION BY PHYSICIAN WITH WRITTEN REPORT" 3058506001_1 CDM 305 RC 85060 HCPCS outpatient 138 103.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 122.82 89 999999999 107.64 131.1 percent of total billed charges "BLOOD SMEAR, PERIPHERAL, INTERPRETATION BY PHYSICIAN WITH WRITTEN REPORT" 3058506001_1 CDM 305 RC 85060 HCPCS outpatient 138 103.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 124.2 90 999999999 107.64 131.1 percent of total billed charges "BLOOD SMEAR, PERIPHERAL, INTERPRETATION BY PHYSICIAN WITH WRITTEN REPORT" 3058506001_1 CDM 305 RC 85060 HCPCS outpatient 138 103.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 131.1 95 999999999 107.64 131.1 percent of total billed charges "BLOOD SMEAR, PERIPHERAL, INTERPRETATION BY PHYSICIAN WITH WRITTEN REPORT" 3058506001_1 CDM 305 RC 85060 HCPCS outpatient 138 103.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 131.1 95 999999999 107.64 131.1 percent of total billed charges "BLOOD SMEAR, PERIPHERAL, INTERPRETATION BY PHYSICIAN WITH WRITTEN REPORT" 3058506001_1 CDM 305 RC 85060 HCPCS outpatient 138 103.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 122.82 89 999999999 107.64 131.1 percent of total billed charges "BLOOD SMEAR, PERIPHERAL, INTERPRETATION BY PHYSICIAN WITH WRITTEN REPORT" 3058506001_1 CDM 305 RC 85060 HCPCS outpatient 138 103.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 121.44 88 999999999 107.64 131.1 percent of total billed charges "BLOOD SMEAR, PERIPHERAL, INTERPRETATION BY PHYSICIAN WITH WRITTEN REPORT" 3058506001_1 CDM 305 RC 85060 HCPCS outpatient 138 103.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 122.82 89 999999999 107.64 131.1 percent of total billed charges "CLOTTING; FACTOR V (ACG OR PROACCELERIN), LABILE FACTOR" 3058522002_1 CDM 305 RC 85220 HCPCS outpatient 170 127.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 153 90 999999999 132.6 161.5 percent of total billed charges "CLOTTING; FACTOR V (ACG OR PROACCELERIN), LABILE FACTOR" 3058522002_1 CDM 305 RC 85220 HCPCS outpatient 170 127.5 AETNA MCR ADV AETNA MCR ADV 132.6 78 999999999 132.6 161.5 percent of total billed charges "CLOTTING; FACTOR V (ACG OR PROACCELERIN), LABILE FACTOR" 3058522002_1 CDM 305 RC 85220 HCPCS outpatient 170 127.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 148.87 87.57 999999999 132.6 161.5 percent of total billed charges "CLOTTING; FACTOR V (ACG OR PROACCELERIN), LABILE FACTOR" 3058522002_1 CDM 305 RC 85220 HCPCS outpatient 170 127.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 144.62 85.07 999999999 132.6 161.5 percent of total billed charges "CLOTTING; FACTOR V (ACG OR PROACCELERIN), LABILE FACTOR" 3058522002_1 CDM 305 RC 85220 HCPCS outpatient 170 127.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 144.62 85.07 999999999 132.6 161.5 percent of total billed charges "CLOTTING; FACTOR V (ACG OR PROACCELERIN), LABILE FACTOR" 3058522002_1 CDM 305 RC 85220 HCPCS outpatient 170 127.5 MOLINA MCAID MOLINA MCAID 141.78 83.4 999999999 132.6 161.5 percent of total billed charges "CLOTTING; FACTOR V (ACG OR PROACCELERIN), LABILE FACTOR" 3058522002_1 CDM 305 RC 85220 HCPCS outpatient 170 127.5 MOLINA MCR ADV MOLINA MCR ADV 151.3 89 999999999 132.6 161.5 percent of total billed charges "CLOTTING; FACTOR V (ACG OR PROACCELERIN), LABILE FACTOR" 3058522002_1 CDM 305 RC 85220 HCPCS outpatient 170 127.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 151.3 89 999999999 132.6 161.5 percent of total billed charges "CLOTTING; FACTOR V (ACG OR PROACCELERIN), LABILE FACTOR" 3058522002_1 CDM 305 RC 85220 HCPCS outpatient 170 127.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 151.3 89 999999999 132.6 161.5 percent of total billed charges "CLOTTING; FACTOR V (ACG OR PROACCELERIN), LABILE FACTOR" 3058522002_1 CDM 305 RC 85220 HCPCS outpatient 170 127.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 153 90 999999999 132.6 161.5 percent of total billed charges "CLOTTING; FACTOR V (ACG OR PROACCELERIN), LABILE FACTOR" 3058522002_1 CDM 305 RC 85220 HCPCS outpatient 170 127.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 161.5 95 999999999 132.6 161.5 percent of total billed charges "CLOTTING; FACTOR V (ACG OR PROACCELERIN), LABILE FACTOR" 3058522002_1 CDM 305 RC 85220 HCPCS outpatient 170 127.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 161.5 95 999999999 132.6 161.5 percent of total billed charges "CLOTTING; FACTOR V (ACG OR PROACCELERIN), LABILE FACTOR" 3058522002_1 CDM 305 RC 85220 HCPCS outpatient 170 127.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 151.3 89 999999999 132.6 161.5 percent of total billed charges "CLOTTING; FACTOR V (ACG OR PROACCELERIN), LABILE FACTOR" 3058522002_1 CDM 305 RC 85220 HCPCS outpatient 170 127.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 149.6 88 999999999 132.6 161.5 percent of total billed charges "CLOTTING; FACTOR V (ACG OR PROACCELERIN), LABILE FACTOR" 3058522002_1 CDM 305 RC 85220 HCPCS outpatient 170 127.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 151.3 89 999999999 132.6 161.5 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; ANTITHROMBIN III, ANTIGEN ASSAY" 3058530102_1 CDM 305 RC 85301 HCPCS outpatient 92 69 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 82.8 90 999999999 71.76 87.4 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; ANTITHROMBIN III, ANTIGEN ASSAY" 3058530102_1 CDM 305 RC 85301 HCPCS outpatient 92 69 AETNA MCR ADV AETNA MCR ADV 71.76 78 999999999 71.76 87.4 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; ANTITHROMBIN III, ANTIGEN ASSAY" 3058530102_1 CDM 305 RC 85301 HCPCS outpatient 92 69 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 80.56 87.57 999999999 71.76 87.4 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; ANTITHROMBIN III, ANTIGEN ASSAY" 3058530102_1 CDM 305 RC 85301 HCPCS outpatient 92 69 COORDINATED CARE MCAID COORDINATED CARE MCAID 78.26 85.07 999999999 71.76 87.4 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; ANTITHROMBIN III, ANTIGEN ASSAY" 3058530102_1 CDM 305 RC 85301 HCPCS outpatient 92 69 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 78.26 85.07 999999999 71.76 87.4 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; ANTITHROMBIN III, ANTIGEN ASSAY" 3058530102_1 CDM 305 RC 85301 HCPCS outpatient 92 69 MOLINA MCAID MOLINA MCAID 76.73 83.4 999999999 71.76 87.4 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; ANTITHROMBIN III, ANTIGEN ASSAY" 3058530102_1 CDM 305 RC 85301 HCPCS outpatient 92 69 MOLINA MCR ADV MOLINA MCR ADV 81.88 89 999999999 71.76 87.4 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; ANTITHROMBIN III, ANTIGEN ASSAY" 3058530102_1 CDM 305 RC 85301 HCPCS outpatient 92 69 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 81.88 89 999999999 71.76 87.4 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; ANTITHROMBIN III, ANTIGEN ASSAY" 3058530102_1 CDM 305 RC 85301 HCPCS outpatient 92 69 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 81.88 89 999999999 71.76 87.4 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; ANTITHROMBIN III, ANTIGEN ASSAY" 3058530102_1 CDM 305 RC 85301 HCPCS outpatient 92 69 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 82.8 90 999999999 71.76 87.4 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; ANTITHROMBIN III, ANTIGEN ASSAY" 3058530102_1 CDM 305 RC 85301 HCPCS outpatient 92 69 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 87.4 95 999999999 71.76 87.4 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; ANTITHROMBIN III, ANTIGEN ASSAY" 3058530102_1 CDM 305 RC 85301 HCPCS outpatient 92 69 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 87.4 95 999999999 71.76 87.4 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; ANTITHROMBIN III, ANTIGEN ASSAY" 3058530102_1 CDM 305 RC 85301 HCPCS outpatient 92 69 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 81.88 89 999999999 71.76 87.4 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; ANTITHROMBIN III, ANTIGEN ASSAY" 3058530102_1 CDM 305 RC 85301 HCPCS outpatient 92 69 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 80.96 88 999999999 71.76 87.4 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; ANTITHROMBIN III, ANTIGEN ASSAY" 3058530102_1 CDM 305 RC 85301 HCPCS outpatient 92 69 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 81.88 89 999999999 71.76 87.4 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN C, ACTIVITY" 3058530303_1 CDM 305 RC 85303 HCPCS outpatient 147 110.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 132.3 90 999999999 114.66 139.65 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN C, ACTIVITY" 3058530303_1 CDM 305 RC 85303 HCPCS outpatient 147 110.25 AETNA MCR ADV AETNA MCR ADV 114.66 78 999999999 114.66 139.65 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN C, ACTIVITY" 3058530303_1 CDM 305 RC 85303 HCPCS outpatient 147 110.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 128.73 87.57 999999999 114.66 139.65 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN C, ACTIVITY" 3058530303_1 CDM 305 RC 85303 HCPCS outpatient 147 110.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 125.05 85.07 999999999 114.66 139.65 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN C, ACTIVITY" 3058530303_1 CDM 305 RC 85303 HCPCS outpatient 147 110.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 125.05 85.07 999999999 114.66 139.65 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN C, ACTIVITY" 3058530303_1 CDM 305 RC 85303 HCPCS outpatient 147 110.25 MOLINA MCAID MOLINA MCAID 122.6 83.4 999999999 114.66 139.65 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN C, ACTIVITY" 3058530303_1 CDM 305 RC 85303 HCPCS outpatient 147 110.25 MOLINA MCR ADV MOLINA MCR ADV 130.83 89 999999999 114.66 139.65 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN C, ACTIVITY" 3058530303_1 CDM 305 RC 85303 HCPCS outpatient 147 110.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 130.83 89 999999999 114.66 139.65 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN C, ACTIVITY" 3058530303_1 CDM 305 RC 85303 HCPCS outpatient 147 110.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 130.83 89 999999999 114.66 139.65 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN C, ACTIVITY" 3058530303_1 CDM 305 RC 85303 HCPCS outpatient 147 110.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 132.3 90 999999999 114.66 139.65 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN C, ACTIVITY" 3058530303_1 CDM 305 RC 85303 HCPCS outpatient 147 110.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 139.65 95 999999999 114.66 139.65 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN C, ACTIVITY" 3058530303_1 CDM 305 RC 85303 HCPCS outpatient 147 110.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 139.65 95 999999999 114.66 139.65 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN C, ACTIVITY" 3058530303_1 CDM 305 RC 85303 HCPCS outpatient 147 110.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 130.83 89 999999999 114.66 139.65 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN C, ACTIVITY" 3058530303_1 CDM 305 RC 85303 HCPCS outpatient 147 110.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 129.36 88 999999999 114.66 139.65 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN C, ACTIVITY" 3058530303_1 CDM 305 RC 85303 HCPCS outpatient 147 110.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 130.83 89 999999999 114.66 139.65 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN S, FREE" 3058530603_1 CDM 305 RC 85306 HCPCS outpatient 194 145.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 174.6 90 999999999 151.32 184.3 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN S, FREE" 3058530603_1 CDM 305 RC 85306 HCPCS outpatient 194 145.5 AETNA MCR ADV AETNA MCR ADV 151.32 78 999999999 151.32 184.3 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN S, FREE" 3058530603_1 CDM 305 RC 85306 HCPCS outpatient 194 145.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 169.89 87.57 999999999 151.32 184.3 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN S, FREE" 3058530603_1 CDM 305 RC 85306 HCPCS outpatient 194 145.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 165.04 85.07 999999999 151.32 184.3 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN S, FREE" 3058530603_1 CDM 305 RC 85306 HCPCS outpatient 194 145.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 165.04 85.07 999999999 151.32 184.3 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN S, FREE" 3058530603_1 CDM 305 RC 85306 HCPCS outpatient 194 145.5 MOLINA MCAID MOLINA MCAID 161.8 83.4 999999999 151.32 184.3 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN S, FREE" 3058530603_1 CDM 305 RC 85306 HCPCS outpatient 194 145.5 MOLINA MCR ADV MOLINA MCR ADV 172.66 89 999999999 151.32 184.3 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN S, FREE" 3058530603_1 CDM 305 RC 85306 HCPCS outpatient 194 145.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 172.66 89 999999999 151.32 184.3 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN S, FREE" 3058530603_1 CDM 305 RC 85306 HCPCS outpatient 194 145.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 172.66 89 999999999 151.32 184.3 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN S, FREE" 3058530603_1 CDM 305 RC 85306 HCPCS outpatient 194 145.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 174.6 90 999999999 151.32 184.3 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN S, FREE" 3058530603_1 CDM 305 RC 85306 HCPCS outpatient 194 145.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 184.3 95 999999999 151.32 184.3 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN S, FREE" 3058530603_1 CDM 305 RC 85306 HCPCS outpatient 194 145.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 184.3 95 999999999 151.32 184.3 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN S, FREE" 3058530603_1 CDM 305 RC 85306 HCPCS outpatient 194 145.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 172.66 89 999999999 151.32 184.3 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN S, FREE" 3058530603_1 CDM 305 RC 85306 HCPCS outpatient 194 145.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 170.72 88 999999999 151.32 184.3 percent of total billed charges "CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN S, FREE" 3058530603_1 CDM 305 RC 85306 HCPCS outpatient 194 145.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 172.66 89 999999999 151.32 184.3 percent of total billed charges "FIBRIN DEGRADATION PRODUCTS, D-DIMER; QUANTITATIVE" 3058537902_1 CDM 305 RC 85379 HCPCS outpatient 148 111 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 133.2 90 999999999 115.44 140.6 percent of total billed charges "FIBRIN DEGRADATION PRODUCTS, D-DIMER; QUANTITATIVE" 3058537902_1 CDM 305 RC 85379 HCPCS outpatient 148 111 AETNA MCR ADV AETNA MCR ADV 115.44 78 999999999 115.44 140.6 percent of total billed charges "FIBRIN DEGRADATION PRODUCTS, D-DIMER; QUANTITATIVE" 3058537902_1 CDM 305 RC 85379 HCPCS outpatient 148 111 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 129.6 87.57 999999999 115.44 140.6 percent of total billed charges "FIBRIN DEGRADATION PRODUCTS, D-DIMER; QUANTITATIVE" 3058537902_1 CDM 305 RC 85379 HCPCS outpatient 148 111 COORDINATED CARE MCAID COORDINATED CARE MCAID 125.9 85.07 999999999 115.44 140.6 percent of total billed charges "FIBRIN DEGRADATION PRODUCTS, D-DIMER; QUANTITATIVE" 3058537902_1 CDM 305 RC 85379 HCPCS outpatient 148 111 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 125.9 85.07 999999999 115.44 140.6 percent of total billed charges "FIBRIN DEGRADATION PRODUCTS, D-DIMER; QUANTITATIVE" 3058537902_1 CDM 305 RC 85379 HCPCS outpatient 148 111 MOLINA MCAID MOLINA MCAID 123.43 83.4 999999999 115.44 140.6 percent of total billed charges "FIBRIN DEGRADATION PRODUCTS, D-DIMER; QUANTITATIVE" 3058537902_1 CDM 305 RC 85379 HCPCS outpatient 148 111 MOLINA MCR ADV MOLINA MCR ADV 131.72 89 999999999 115.44 140.6 percent of total billed charges "FIBRIN DEGRADATION PRODUCTS, D-DIMER; QUANTITATIVE" 3058537902_1 CDM 305 RC 85379 HCPCS outpatient 148 111 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 131.72 89 999999999 115.44 140.6 percent of total billed charges "FIBRIN DEGRADATION PRODUCTS, D-DIMER; QUANTITATIVE" 3058537902_1 CDM 305 RC 85379 HCPCS outpatient 148 111 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 131.72 89 999999999 115.44 140.6 percent of total billed charges "FIBRIN DEGRADATION PRODUCTS, D-DIMER; QUANTITATIVE" 3058537902_1 CDM 305 RC 85379 HCPCS outpatient 148 111 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 133.2 90 999999999 115.44 140.6 percent of total billed charges "FIBRIN DEGRADATION PRODUCTS, D-DIMER; QUANTITATIVE" 3058537902_1 CDM 305 RC 85379 HCPCS outpatient 148 111 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 140.6 95 999999999 115.44 140.6 percent of total billed charges "FIBRIN DEGRADATION PRODUCTS, D-DIMER; QUANTITATIVE" 3058537902_1 CDM 305 RC 85379 HCPCS outpatient 148 111 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 140.6 95 999999999 115.44 140.6 percent of total billed charges "FIBRIN DEGRADATION PRODUCTS, D-DIMER; QUANTITATIVE" 3058537902_1 CDM 305 RC 85379 HCPCS outpatient 148 111 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 131.72 89 999999999 115.44 140.6 percent of total billed charges "FIBRIN DEGRADATION PRODUCTS, D-DIMER; QUANTITATIVE" 3058537902_1 CDM 305 RC 85379 HCPCS outpatient 148 111 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 130.24 88 999999999 115.44 140.6 percent of total billed charges "FIBRIN DEGRADATION PRODUCTS, D-DIMER; QUANTITATIVE" 3058537902_1 CDM 305 RC 85379 HCPCS outpatient 148 111 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 131.72 89 999999999 115.44 140.6 percent of total billed charges FIBRINOGEN; ACTIVITY 3058538401_1 CDM 305 RC 85384 HCPCS outpatient 104 78 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 93.6 90 999999999 81.12 98.8 percent of total billed charges FIBRINOGEN; ACTIVITY 3058538401_1 CDM 305 RC 85384 HCPCS outpatient 104 78 AETNA MCR ADV AETNA MCR ADV 81.12 78 999999999 81.12 98.8 percent of total billed charges FIBRINOGEN; ACTIVITY 3058538401_1 CDM 305 RC 85384 HCPCS outpatient 104 78 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 91.07 87.57 999999999 81.12 98.8 percent of total billed charges FIBRINOGEN; ACTIVITY 3058538401_1 CDM 305 RC 85384 HCPCS outpatient 104 78 COORDINATED CARE MCAID COORDINATED CARE MCAID 88.47 85.07 999999999 81.12 98.8 percent of total billed charges FIBRINOGEN; ACTIVITY 3058538401_1 CDM 305 RC 85384 HCPCS outpatient 104 78 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 88.47 85.07 999999999 81.12 98.8 percent of total billed charges FIBRINOGEN; ACTIVITY 3058538401_1 CDM 305 RC 85384 HCPCS outpatient 104 78 MOLINA MCAID MOLINA MCAID 86.74 83.4 999999999 81.12 98.8 percent of total billed charges FIBRINOGEN; ACTIVITY 3058538401_1 CDM 305 RC 85384 HCPCS outpatient 104 78 MOLINA MCR ADV MOLINA MCR ADV 92.56 89 999999999 81.12 98.8 percent of total billed charges FIBRINOGEN; ACTIVITY 3058538401_1 CDM 305 RC 85384 HCPCS outpatient 104 78 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 92.56 89 999999999 81.12 98.8 percent of total billed charges FIBRINOGEN; ACTIVITY 3058538401_1 CDM 305 RC 85384 HCPCS outpatient 104 78 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 92.56 89 999999999 81.12 98.8 percent of total billed charges FIBRINOGEN; ACTIVITY 3058538401_1 CDM 305 RC 85384 HCPCS outpatient 104 78 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 93.6 90 999999999 81.12 98.8 percent of total billed charges FIBRINOGEN; ACTIVITY 3058538401_1 CDM 305 RC 85384 HCPCS outpatient 104 78 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 98.8 95 999999999 81.12 98.8 percent of total billed charges FIBRINOGEN; ACTIVITY 3058538401_1 CDM 305 RC 85384 HCPCS outpatient 104 78 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 98.8 95 999999999 81.12 98.8 percent of total billed charges FIBRINOGEN; ACTIVITY 3058538401_1 CDM 305 RC 85384 HCPCS outpatient 104 78 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 92.56 89 999999999 81.12 98.8 percent of total billed charges FIBRINOGEN; ACTIVITY 3058538401_1 CDM 305 RC 85384 HCPCS outpatient 104 78 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 91.52 88 999999999 81.12 98.8 percent of total billed charges FIBRINOGEN; ACTIVITY 3058538401_1 CDM 305 RC 85384 HCPCS outpatient 104 78 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 92.56 89 999999999 81.12 98.8 percent of total billed charges HEPARIN ASSAY 3058552002_1 CDM 305 RC 85520 HCPCS outpatient 251 188.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 225.9 90 999999999 195.78 238.45 percent of total billed charges HEPARIN ASSAY 3058552002_1 CDM 305 RC 85520 HCPCS outpatient 251 188.25 AETNA MCR ADV AETNA MCR ADV 195.78 78 999999999 195.78 238.45 percent of total billed charges HEPARIN ASSAY 3058552002_1 CDM 305 RC 85520 HCPCS outpatient 251 188.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 219.8 87.57 999999999 195.78 238.45 percent of total billed charges HEPARIN ASSAY 3058552002_1 CDM 305 RC 85520 HCPCS outpatient 251 188.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 213.53 85.07 999999999 195.78 238.45 percent of total billed charges HEPARIN ASSAY 3058552002_1 CDM 305 RC 85520 HCPCS outpatient 251 188.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 213.53 85.07 999999999 195.78 238.45 percent of total billed charges HEPARIN ASSAY 3058552002_1 CDM 305 RC 85520 HCPCS outpatient 251 188.25 MOLINA MCAID MOLINA MCAID 209.33 83.4 999999999 195.78 238.45 percent of total billed charges HEPARIN ASSAY 3058552002_1 CDM 305 RC 85520 HCPCS outpatient 251 188.25 MOLINA MCR ADV MOLINA MCR ADV 223.39 89 999999999 195.78 238.45 percent of total billed charges HEPARIN ASSAY 3058552002_1 CDM 305 RC 85520 HCPCS outpatient 251 188.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 223.39 89 999999999 195.78 238.45 percent of total billed charges HEPARIN ASSAY 3058552002_1 CDM 305 RC 85520 HCPCS outpatient 251 188.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 223.39 89 999999999 195.78 238.45 percent of total billed charges HEPARIN ASSAY 3058552002_1 CDM 305 RC 85520 HCPCS outpatient 251 188.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 225.9 90 999999999 195.78 238.45 percent of total billed charges HEPARIN ASSAY 3058552002_1 CDM 305 RC 85520 HCPCS outpatient 251 188.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 238.45 95 999999999 195.78 238.45 percent of total billed charges HEPARIN ASSAY 3058552002_1 CDM 305 RC 85520 HCPCS outpatient 251 188.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 238.45 95 999999999 195.78 238.45 percent of total billed charges HEPARIN ASSAY 3058552002_1 CDM 305 RC 85520 HCPCS outpatient 251 188.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 223.39 89 999999999 195.78 238.45 percent of total billed charges HEPARIN ASSAY 3058552002_1 CDM 305 RC 85520 HCPCS outpatient 251 188.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 220.88 88 999999999 195.78 238.45 percent of total billed charges HEPARIN ASSAY 3058552002_1 CDM 305 RC 85520 HCPCS outpatient 251 188.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 223.39 89 999999999 195.78 238.45 percent of total billed charges PROTHROMBIN TIME 3058561001_1 CDM 305 RC 85610 HCPCS outpatient 56 42 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50.4 90 999999999 43.68 53.2 percent of total billed charges PROTHROMBIN TIME 3058561001_1 CDM 305 RC 85610 HCPCS outpatient 56 42 AETNA MCR ADV AETNA MCR ADV 43.68 78 999999999 43.68 53.2 percent of total billed charges PROTHROMBIN TIME 3058561001_1 CDM 305 RC 85610 HCPCS outpatient 56 42 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 49.04 87.57 999999999 43.68 53.2 percent of total billed charges PROTHROMBIN TIME 3058561001_1 CDM 305 RC 85610 HCPCS outpatient 56 42 COORDINATED CARE MCAID COORDINATED CARE MCAID 47.64 85.07 999999999 43.68 53.2 percent of total billed charges PROTHROMBIN TIME 3058561001_1 CDM 305 RC 85610 HCPCS outpatient 56 42 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 47.64 85.07 999999999 43.68 53.2 percent of total billed charges PROTHROMBIN TIME 3058561001_1 CDM 305 RC 85610 HCPCS outpatient 56 42 MOLINA MCAID MOLINA MCAID 46.7 83.4 999999999 43.68 53.2 percent of total billed charges PROTHROMBIN TIME 3058561001_1 CDM 305 RC 85610 HCPCS outpatient 56 42 MOLINA MCR ADV MOLINA MCR ADV 49.84 89 999999999 43.68 53.2 percent of total billed charges PROTHROMBIN TIME 3058561001_1 CDM 305 RC 85610 HCPCS outpatient 56 42 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 49.84 89 999999999 43.68 53.2 percent of total billed charges PROTHROMBIN TIME 3058561001_1 CDM 305 RC 85610 HCPCS outpatient 56 42 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 49.84 89 999999999 43.68 53.2 percent of total billed charges PROTHROMBIN TIME 3058561001_1 CDM 305 RC 85610 HCPCS outpatient 56 42 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50.4 90 999999999 43.68 53.2 percent of total billed charges PROTHROMBIN TIME 3058561001_1 CDM 305 RC 85610 HCPCS outpatient 56 42 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 53.2 95 999999999 43.68 53.2 percent of total billed charges PROTHROMBIN TIME 3058561001_1 CDM 305 RC 85610 HCPCS outpatient 56 42 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 53.2 95 999999999 43.68 53.2 percent of total billed charges PROTHROMBIN TIME 3058561001_1 CDM 305 RC 85610 HCPCS outpatient 56 42 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 49.84 89 999999999 43.68 53.2 percent of total billed charges PROTHROMBIN TIME 3058561001_1 CDM 305 RC 85610 HCPCS outpatient 56 42 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 49.28 88 999999999 43.68 53.2 percent of total billed charges PROTHROMBIN TIME 3058561001_1 CDM 305 RC 85610 HCPCS outpatient 56 42 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 49.84 89 999999999 43.68 53.2 percent of total billed charges "SEDIMENTATION RATE, ERYTHROCYTE; NON-AUTOMATED" 3058565101_1 CDM 305 RC 85651 HCPCS outpatient 59 44.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 53.1 90 999999999 46.02 56.05 percent of total billed charges "SEDIMENTATION RATE, ERYTHROCYTE; NON-AUTOMATED" 3058565101_1 CDM 305 RC 85651 HCPCS outpatient 59 44.25 AETNA MCR ADV AETNA MCR ADV 46.02 78 999999999 46.02 56.05 percent of total billed charges "SEDIMENTATION RATE, ERYTHROCYTE; NON-AUTOMATED" 3058565101_1 CDM 305 RC 85651 HCPCS outpatient 59 44.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 51.67 87.57 999999999 46.02 56.05 percent of total billed charges "SEDIMENTATION RATE, ERYTHROCYTE; NON-AUTOMATED" 3058565101_1 CDM 305 RC 85651 HCPCS outpatient 59 44.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 50.19 85.07 999999999 46.02 56.05 percent of total billed charges "SEDIMENTATION RATE, ERYTHROCYTE; NON-AUTOMATED" 3058565101_1 CDM 305 RC 85651 HCPCS outpatient 59 44.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50.19 85.07 999999999 46.02 56.05 percent of total billed charges "SEDIMENTATION RATE, ERYTHROCYTE; NON-AUTOMATED" 3058565101_1 CDM 305 RC 85651 HCPCS outpatient 59 44.25 MOLINA MCAID MOLINA MCAID 49.21 83.4 999999999 46.02 56.05 percent of total billed charges "SEDIMENTATION RATE, ERYTHROCYTE; NON-AUTOMATED" 3058565101_1 CDM 305 RC 85651 HCPCS outpatient 59 44.25 MOLINA MCR ADV MOLINA MCR ADV 52.51 89 999999999 46.02 56.05 percent of total billed charges "SEDIMENTATION RATE, ERYTHROCYTE; NON-AUTOMATED" 3058565101_1 CDM 305 RC 85651 HCPCS outpatient 59 44.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 52.51 89 999999999 46.02 56.05 percent of total billed charges "SEDIMENTATION RATE, ERYTHROCYTE; NON-AUTOMATED" 3058565101_1 CDM 305 RC 85651 HCPCS outpatient 59 44.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 52.51 89 999999999 46.02 56.05 percent of total billed charges "SEDIMENTATION RATE, ERYTHROCYTE; NON-AUTOMATED" 3058565101_1 CDM 305 RC 85651 HCPCS outpatient 59 44.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 53.1 90 999999999 46.02 56.05 percent of total billed charges "SEDIMENTATION RATE, ERYTHROCYTE; NON-AUTOMATED" 3058565101_1 CDM 305 RC 85651 HCPCS outpatient 59 44.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 56.05 95 999999999 46.02 56.05 percent of total billed charges "SEDIMENTATION RATE, ERYTHROCYTE; NON-AUTOMATED" 3058565101_1 CDM 305 RC 85651 HCPCS outpatient 59 44.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 56.05 95 999999999 46.02 56.05 percent of total billed charges "SEDIMENTATION RATE, ERYTHROCYTE; NON-AUTOMATED" 3058565101_1 CDM 305 RC 85651 HCPCS outpatient 59 44.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 52.51 89 999999999 46.02 56.05 percent of total billed charges "SEDIMENTATION RATE, ERYTHROCYTE; NON-AUTOMATED" 3058565101_1 CDM 305 RC 85651 HCPCS outpatient 59 44.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 51.92 88 999999999 46.02 56.05 percent of total billed charges "SEDIMENTATION RATE, ERYTHROCYTE; NON-AUTOMATED" 3058565101_1 CDM 305 RC 85651 HCPCS outpatient 59 44.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 52.51 89 999999999 46.02 56.05 percent of total billed charges "SEDIMENTATION RATE, ERYTHROCYTE; AUTOMATED" 3058565201_1 CDM 305 RC 85652 HCPCS outpatient 59.87 44.9 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 53.88 90 999999999 46.7 56.88 percent of total billed charges "SEDIMENTATION RATE, ERYTHROCYTE; AUTOMATED" 3058565201_1 CDM 305 RC 85652 HCPCS outpatient 59.87 44.9 AETNA MCR ADV AETNA MCR ADV 46.7 78 999999999 46.7 56.88 percent of total billed charges "SEDIMENTATION RATE, ERYTHROCYTE; AUTOMATED" 3058565201_1 CDM 305 RC 85652 HCPCS outpatient 59.87 44.9 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 52.43 87.57 999999999 46.7 56.88 percent of total billed charges "SEDIMENTATION RATE, ERYTHROCYTE; AUTOMATED" 3058565201_1 CDM 305 RC 85652 HCPCS outpatient 59.87 44.9 COORDINATED CARE MCAID COORDINATED CARE MCAID 50.93 85.07 999999999 46.7 56.88 percent of total billed charges "SEDIMENTATION RATE, ERYTHROCYTE; AUTOMATED" 3058565201_1 CDM 305 RC 85652 HCPCS outpatient 59.87 44.9 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50.93 85.07 999999999 46.7 56.88 percent of total billed charges "SEDIMENTATION RATE, ERYTHROCYTE; AUTOMATED" 3058565201_1 CDM 305 RC 85652 HCPCS outpatient 59.87 44.9 MOLINA MCAID MOLINA MCAID 49.93 83.4 999999999 46.7 56.88 percent of total billed charges "SEDIMENTATION RATE, ERYTHROCYTE; AUTOMATED" 3058565201_1 CDM 305 RC 85652 HCPCS outpatient 59.87 44.9 MOLINA MCR ADV MOLINA MCR ADV 53.28 89 999999999 46.7 56.88 percent of total billed charges "SEDIMENTATION RATE, ERYTHROCYTE; AUTOMATED" 3058565201_1 CDM 305 RC 85652 HCPCS outpatient 59.87 44.9 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 53.28 89 999999999 46.7 56.88 percent of total billed charges "SEDIMENTATION RATE, ERYTHROCYTE; AUTOMATED" 3058565201_1 CDM 305 RC 85652 HCPCS outpatient 59.87 44.9 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 53.28 89 999999999 46.7 56.88 percent of total billed charges "SEDIMENTATION RATE, ERYTHROCYTE; AUTOMATED" 3058565201_1 CDM 305 RC 85652 HCPCS outpatient 59.87 44.9 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 53.88 90 999999999 46.7 56.88 percent of total billed charges "SEDIMENTATION RATE, ERYTHROCYTE; AUTOMATED" 3058565201_1 CDM 305 RC 85652 HCPCS outpatient 59.87 44.9 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 56.88 95 999999999 46.7 56.88 percent of total billed charges "SEDIMENTATION RATE, ERYTHROCYTE; AUTOMATED" 3058565201_1 CDM 305 RC 85652 HCPCS outpatient 59.87 44.9 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 56.88 95 999999999 46.7 56.88 percent of total billed charges "SEDIMENTATION RATE, ERYTHROCYTE; AUTOMATED" 3058565201_1 CDM 305 RC 85652 HCPCS outpatient 59.87 44.9 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 53.28 89 999999999 46.7 56.88 percent of total billed charges "SEDIMENTATION RATE, ERYTHROCYTE; AUTOMATED" 3058565201_1 CDM 305 RC 85652 HCPCS outpatient 59.87 44.9 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 52.69 88 999999999 46.7 56.88 percent of total billed charges "SEDIMENTATION RATE, ERYTHROCYTE; AUTOMATED" 3058565201_1 CDM 305 RC 85652 HCPCS outpatient 59.87 44.9 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 53.28 89 999999999 46.7 56.88 percent of total billed charges "SICKLING OF RBC, REDUCTION" 3058566002_1 CDM 390 RC 85660 HCPCS outpatient 129 96.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 116.1 90 999999999 100.62 122.55 percent of total billed charges "SICKLING OF RBC, REDUCTION" 3058566002_1 CDM 390 RC 85660 HCPCS outpatient 129 96.75 AETNA MCR ADV AETNA MCR ADV 100.62 78 999999999 100.62 122.55 percent of total billed charges "SICKLING OF RBC, REDUCTION" 3058566002_1 CDM 390 RC 85660 HCPCS outpatient 129 96.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 112.97 87.57 999999999 100.62 122.55 percent of total billed charges "SICKLING OF RBC, REDUCTION" 3058566002_1 CDM 390 RC 85660 HCPCS outpatient 129 96.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 109.74 85.07 999999999 100.62 122.55 percent of total billed charges "SICKLING OF RBC, REDUCTION" 3058566002_1 CDM 390 RC 85660 HCPCS outpatient 129 96.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 109.74 85.07 999999999 100.62 122.55 percent of total billed charges "SICKLING OF RBC, REDUCTION" 3058566002_1 CDM 390 RC 85660 HCPCS outpatient 129 96.75 MOLINA MCAID MOLINA MCAID 107.59 83.4 999999999 100.62 122.55 percent of total billed charges "SICKLING OF RBC, REDUCTION" 3058566002_1 CDM 390 RC 85660 HCPCS outpatient 129 96.75 MOLINA MCR ADV MOLINA MCR ADV 114.81 89 999999999 100.62 122.55 percent of total billed charges "SICKLING OF RBC, REDUCTION" 3058566002_1 CDM 390 RC 85660 HCPCS outpatient 129 96.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 114.81 89 999999999 100.62 122.55 percent of total billed charges "SICKLING OF RBC, REDUCTION" 3058566002_1 CDM 390 RC 85660 HCPCS outpatient 129 96.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 114.81 89 999999999 100.62 122.55 percent of total billed charges "SICKLING OF RBC, REDUCTION" 3058566002_1 CDM 390 RC 85660 HCPCS outpatient 129 96.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 116.1 90 999999999 100.62 122.55 percent of total billed charges "SICKLING OF RBC, REDUCTION" 3058566002_1 CDM 390 RC 85660 HCPCS outpatient 129 96.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 122.55 95 999999999 100.62 122.55 percent of total billed charges "SICKLING OF RBC, REDUCTION" 3058566002_1 CDM 390 RC 85660 HCPCS outpatient 129 96.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 122.55 95 999999999 100.62 122.55 percent of total billed charges "SICKLING OF RBC, REDUCTION" 3058566002_1 CDM 390 RC 85660 HCPCS outpatient 129 96.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 114.81 89 999999999 100.62 122.55 percent of total billed charges "SICKLING OF RBC, REDUCTION" 3058566002_1 CDM 390 RC 85660 HCPCS outpatient 129 96.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 113.52 88 999999999 100.62 122.55 percent of total billed charges "SICKLING OF RBC, REDUCTION" 3058566002_1 CDM 390 RC 85660 HCPCS outpatient 129 96.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 114.81 89 999999999 100.62 122.55 percent of total billed charges "THROMBOPLASTIN TIME, PARTIAL (PTT); PLASMA OR WHOLE BLOOD" 3058573001_1 CDM 305 RC 85730 HCPCS outpatient 105 78.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 94.5 90 999999999 81.9 99.75 percent of total billed charges "THROMBOPLASTIN TIME, PARTIAL (PTT); PLASMA OR WHOLE BLOOD" 3058573001_1 CDM 305 RC 85730 HCPCS outpatient 105 78.75 AETNA MCR ADV AETNA MCR ADV 81.9 78 999999999 81.9 99.75 percent of total billed charges "THROMBOPLASTIN TIME, PARTIAL (PTT); PLASMA OR WHOLE BLOOD" 3058573001_1 CDM 305 RC 85730 HCPCS outpatient 105 78.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 91.95 87.57 999999999 81.9 99.75 percent of total billed charges "THROMBOPLASTIN TIME, PARTIAL (PTT); PLASMA OR WHOLE BLOOD" 3058573001_1 CDM 305 RC 85730 HCPCS outpatient 105 78.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 89.32 85.07 999999999 81.9 99.75 percent of total billed charges "THROMBOPLASTIN TIME, PARTIAL (PTT); PLASMA OR WHOLE BLOOD" 3058573001_1 CDM 305 RC 85730 HCPCS outpatient 105 78.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 89.32 85.07 999999999 81.9 99.75 percent of total billed charges "THROMBOPLASTIN TIME, PARTIAL (PTT); PLASMA OR WHOLE BLOOD" 3058573001_1 CDM 305 RC 85730 HCPCS outpatient 105 78.75 MOLINA MCAID MOLINA MCAID 87.57 83.4 999999999 81.9 99.75 percent of total billed charges "THROMBOPLASTIN TIME, PARTIAL (PTT); PLASMA OR WHOLE BLOOD" 3058573001_1 CDM 305 RC 85730 HCPCS outpatient 105 78.75 MOLINA MCR ADV MOLINA MCR ADV 93.45 89 999999999 81.9 99.75 percent of total billed charges "THROMBOPLASTIN TIME, PARTIAL (PTT); PLASMA OR WHOLE BLOOD" 3058573001_1 CDM 305 RC 85730 HCPCS outpatient 105 78.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 93.45 89 999999999 81.9 99.75 percent of total billed charges "THROMBOPLASTIN TIME, PARTIAL (PTT); PLASMA OR WHOLE BLOOD" 3058573001_1 CDM 305 RC 85730 HCPCS outpatient 105 78.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 93.45 89 999999999 81.9 99.75 percent of total billed charges "THROMBOPLASTIN TIME, PARTIAL (PTT); PLASMA OR WHOLE BLOOD" 3058573001_1 CDM 305 RC 85730 HCPCS outpatient 105 78.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 94.5 90 999999999 81.9 99.75 percent of total billed charges "THROMBOPLASTIN TIME, PARTIAL (PTT); PLASMA OR WHOLE BLOOD" 3058573001_1 CDM 305 RC 85730 HCPCS outpatient 105 78.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 99.75 95 999999999 81.9 99.75 percent of total billed charges "THROMBOPLASTIN TIME, PARTIAL (PTT); PLASMA OR WHOLE BLOOD" 3058573001_1 CDM 305 RC 85730 HCPCS outpatient 105 78.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 99.75 95 999999999 81.9 99.75 percent of total billed charges "THROMBOPLASTIN TIME, PARTIAL (PTT); PLASMA OR WHOLE BLOOD" 3058573001_1 CDM 305 RC 85730 HCPCS outpatient 105 78.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 93.45 89 999999999 81.9 99.75 percent of total billed charges "THROMBOPLASTIN TIME, PARTIAL (PTT); PLASMA OR WHOLE BLOOD" 3058573001_1 CDM 305 RC 85730 HCPCS outpatient 105 78.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 92.4 88 999999999 81.9 99.75 percent of total billed charges "THROMBOPLASTIN TIME, PARTIAL (PTT); PLASMA OR WHOLE BLOOD" 3058573001_1 CDM 305 RC 85730 HCPCS outpatient 105 78.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 93.45 89 999999999 81.9 99.75 percent of total billed charges "THROMBOPLASTIN TIME, PARTIAL (PTT); SUBSTITUTION, PLASMA FRACTIONS, EACH" 3058573203_1 CDM 305 RC 85732 HCPCS outpatient 61 45.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 54.9 90 999999999 47.58 57.95 percent of total billed charges "THROMBOPLASTIN TIME, PARTIAL (PTT); SUBSTITUTION, PLASMA FRACTIONS, EACH" 3058573203_1 CDM 305 RC 85732 HCPCS outpatient 61 45.75 AETNA MCR ADV AETNA MCR ADV 47.58 78 999999999 47.58 57.95 percent of total billed charges "THROMBOPLASTIN TIME, PARTIAL (PTT); SUBSTITUTION, PLASMA FRACTIONS, EACH" 3058573203_1 CDM 305 RC 85732 HCPCS outpatient 61 45.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 53.42 87.57 999999999 47.58 57.95 percent of total billed charges "THROMBOPLASTIN TIME, PARTIAL (PTT); SUBSTITUTION, PLASMA FRACTIONS, EACH" 3058573203_1 CDM 305 RC 85732 HCPCS outpatient 61 45.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 51.89 85.07 999999999 47.58 57.95 percent of total billed charges "THROMBOPLASTIN TIME, PARTIAL (PTT); SUBSTITUTION, PLASMA FRACTIONS, EACH" 3058573203_1 CDM 305 RC 85732 HCPCS outpatient 61 45.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 51.89 85.07 999999999 47.58 57.95 percent of total billed charges "THROMBOPLASTIN TIME, PARTIAL (PTT); SUBSTITUTION, PLASMA FRACTIONS, EACH" 3058573203_1 CDM 305 RC 85732 HCPCS outpatient 61 45.75 MOLINA MCAID MOLINA MCAID 50.87 83.4 999999999 47.58 57.95 percent of total billed charges "THROMBOPLASTIN TIME, PARTIAL (PTT); SUBSTITUTION, PLASMA FRACTIONS, EACH" 3058573203_1 CDM 305 RC 85732 HCPCS outpatient 61 45.75 MOLINA MCR ADV MOLINA MCR ADV 54.29 89 999999999 47.58 57.95 percent of total billed charges "THROMBOPLASTIN TIME, PARTIAL (PTT); SUBSTITUTION, PLASMA FRACTIONS, EACH" 3058573203_1 CDM 305 RC 85732 HCPCS outpatient 61 45.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 54.29 89 999999999 47.58 57.95 percent of total billed charges "THROMBOPLASTIN TIME, PARTIAL (PTT); SUBSTITUTION, PLASMA FRACTIONS, EACH" 3058573203_1 CDM 305 RC 85732 HCPCS outpatient 61 45.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 54.29 89 999999999 47.58 57.95 percent of total billed charges "THROMBOPLASTIN TIME, PARTIAL (PTT); SUBSTITUTION, PLASMA FRACTIONS, EACH" 3058573203_1 CDM 305 RC 85732 HCPCS outpatient 61 45.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 54.9 90 999999999 47.58 57.95 percent of total billed charges "THROMBOPLASTIN TIME, PARTIAL (PTT); SUBSTITUTION, PLASMA FRACTIONS, EACH" 3058573203_1 CDM 305 RC 85732 HCPCS outpatient 61 45.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 57.95 95 999999999 47.58 57.95 percent of total billed charges "THROMBOPLASTIN TIME, PARTIAL (PTT); SUBSTITUTION, PLASMA FRACTIONS, EACH" 3058573203_1 CDM 305 RC 85732 HCPCS outpatient 61 45.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 57.95 95 999999999 47.58 57.95 percent of total billed charges "THROMBOPLASTIN TIME, PARTIAL (PTT); SUBSTITUTION, PLASMA FRACTIONS, EACH" 3058573203_1 CDM 305 RC 85732 HCPCS outpatient 61 45.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 54.29 89 999999999 47.58 57.95 percent of total billed charges "THROMBOPLASTIN TIME, PARTIAL (PTT); SUBSTITUTION, PLASMA FRACTIONS, EACH" 3058573203_1 CDM 305 RC 85732 HCPCS outpatient 61 45.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 53.68 88 999999999 47.58 57.95 percent of total billed charges "THROMBOPLASTIN TIME, PARTIAL (PTT); SUBSTITUTION, PLASMA FRACTIONS, EACH" 3058573203_1 CDM 305 RC 85732 HCPCS outpatient 61 45.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 54.29 89 999999999 47.58 57.95 percent of total billed charges "CONCENTRATION (ANY TYPE), FOR INFECTIOUS AGENTS" 3068701506_1 CDM 306 RC 87015 HCPCS outpatient 81 60.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 72.9 90 999999999 63.18 76.95 percent of total billed charges "CONCENTRATION (ANY TYPE), FOR INFECTIOUS AGENTS" 3068701506_1 CDM 306 RC 87015 HCPCS outpatient 81 60.75 AETNA MCR ADV AETNA MCR ADV 63.18 78 999999999 63.18 76.95 percent of total billed charges "CONCENTRATION (ANY TYPE), FOR INFECTIOUS AGENTS" 3068701506_1 CDM 306 RC 87015 HCPCS outpatient 81 60.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 70.93 87.57 999999999 63.18 76.95 percent of total billed charges "CONCENTRATION (ANY TYPE), FOR INFECTIOUS AGENTS" 3068701506_1 CDM 306 RC 87015 HCPCS outpatient 81 60.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 68.91 85.07 999999999 63.18 76.95 percent of total billed charges "CONCENTRATION (ANY TYPE), FOR INFECTIOUS AGENTS" 3068701506_1 CDM 306 RC 87015 HCPCS outpatient 81 60.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 68.91 85.07 999999999 63.18 76.95 percent of total billed charges "CONCENTRATION (ANY TYPE), FOR INFECTIOUS AGENTS" 3068701506_1 CDM 306 RC 87015 HCPCS outpatient 81 60.75 MOLINA MCAID MOLINA MCAID 67.55 83.4 999999999 63.18 76.95 percent of total billed charges "CONCENTRATION (ANY TYPE), FOR INFECTIOUS AGENTS" 3068701506_1 CDM 306 RC 87015 HCPCS outpatient 81 60.75 MOLINA MCR ADV MOLINA MCR ADV 72.09 89 999999999 63.18 76.95 percent of total billed charges "CONCENTRATION (ANY TYPE), FOR INFECTIOUS AGENTS" 3068701506_1 CDM 306 RC 87015 HCPCS outpatient 81 60.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 72.09 89 999999999 63.18 76.95 percent of total billed charges "CONCENTRATION (ANY TYPE), FOR INFECTIOUS AGENTS" 3068701506_1 CDM 306 RC 87015 HCPCS outpatient 81 60.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 72.09 89 999999999 63.18 76.95 percent of total billed charges "CONCENTRATION (ANY TYPE), FOR INFECTIOUS AGENTS" 3068701506_1 CDM 306 RC 87015 HCPCS outpatient 81 60.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 72.9 90 999999999 63.18 76.95 percent of total billed charges "CONCENTRATION (ANY TYPE), FOR INFECTIOUS AGENTS" 3068701506_1 CDM 306 RC 87015 HCPCS outpatient 81 60.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 76.95 95 999999999 63.18 76.95 percent of total billed charges "CONCENTRATION (ANY TYPE), FOR INFECTIOUS AGENTS" 3068701506_1 CDM 306 RC 87015 HCPCS outpatient 81 60.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 76.95 95 999999999 63.18 76.95 percent of total billed charges "CONCENTRATION (ANY TYPE), FOR INFECTIOUS AGENTS" 3068701506_1 CDM 306 RC 87015 HCPCS outpatient 81 60.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 72.09 89 999999999 63.18 76.95 percent of total billed charges "CONCENTRATION (ANY TYPE), FOR INFECTIOUS AGENTS" 3068701506_1 CDM 306 RC 87015 HCPCS outpatient 81 60.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 71.28 88 999999999 63.18 76.95 percent of total billed charges "CONCENTRATION (ANY TYPE), FOR INFECTIOUS AGENTS" 3068701506_1 CDM 306 RC 87015 HCPCS outpatient 81 60.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 72.09 89 999999999 63.18 76.95 percent of total billed charges "CULTURE, BACTERIAL; BLOOD, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES (INCLUDES ANAEROBIC CULTURE, IF APPROPRIATE)" 3068704001_1 CDM 306 RC 87040 HCPCS outpatient 194 145.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 174.6 90 999999999 151.32 184.3 percent of total billed charges "CULTURE, BACTERIAL; BLOOD, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES (INCLUDES ANAEROBIC CULTURE, IF APPROPRIATE)" 3068704001_1 CDM 306 RC 87040 HCPCS outpatient 194 145.5 AETNA MCR ADV AETNA MCR ADV 151.32 78 999999999 151.32 184.3 percent of total billed charges "CULTURE, BACTERIAL; BLOOD, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES (INCLUDES ANAEROBIC CULTURE, IF APPROPRIATE)" 3068704001_1 CDM 306 RC 87040 HCPCS outpatient 194 145.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 169.89 87.57 999999999 151.32 184.3 percent of total billed charges "CULTURE, BACTERIAL; BLOOD, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES (INCLUDES ANAEROBIC CULTURE, IF APPROPRIATE)" 3068704001_1 CDM 306 RC 87040 HCPCS outpatient 194 145.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 165.04 85.07 999999999 151.32 184.3 percent of total billed charges "CULTURE, BACTERIAL; BLOOD, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES (INCLUDES ANAEROBIC CULTURE, IF APPROPRIATE)" 3068704001_1 CDM 306 RC 87040 HCPCS outpatient 194 145.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 165.04 85.07 999999999 151.32 184.3 percent of total billed charges "CULTURE, BACTERIAL; BLOOD, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES (INCLUDES ANAEROBIC CULTURE, IF APPROPRIATE)" 3068704001_1 CDM 306 RC 87040 HCPCS outpatient 194 145.5 MOLINA MCAID MOLINA MCAID 161.8 83.4 999999999 151.32 184.3 percent of total billed charges "CULTURE, BACTERIAL; BLOOD, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES (INCLUDES ANAEROBIC CULTURE, IF APPROPRIATE)" 3068704001_1 CDM 306 RC 87040 HCPCS outpatient 194 145.5 MOLINA MCR ADV MOLINA MCR ADV 172.66 89 999999999 151.32 184.3 percent of total billed charges "CULTURE, BACTERIAL; BLOOD, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES (INCLUDES ANAEROBIC CULTURE, IF APPROPRIATE)" 3068704001_1 CDM 306 RC 87040 HCPCS outpatient 194 145.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 172.66 89 999999999 151.32 184.3 percent of total billed charges "CULTURE, BACTERIAL; BLOOD, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES (INCLUDES ANAEROBIC CULTURE, IF APPROPRIATE)" 3068704001_1 CDM 306 RC 87040 HCPCS outpatient 194 145.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 172.66 89 999999999 151.32 184.3 percent of total billed charges "CULTURE, BACTERIAL; BLOOD, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES (INCLUDES ANAEROBIC CULTURE, IF APPROPRIATE)" 3068704001_1 CDM 306 RC 87040 HCPCS outpatient 194 145.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 174.6 90 999999999 151.32 184.3 percent of total billed charges "CULTURE, BACTERIAL; BLOOD, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES (INCLUDES ANAEROBIC CULTURE, IF APPROPRIATE)" 3068704001_1 CDM 306 RC 87040 HCPCS outpatient 194 145.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 184.3 95 999999999 151.32 184.3 percent of total billed charges "CULTURE, BACTERIAL; BLOOD, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES (INCLUDES ANAEROBIC CULTURE, IF APPROPRIATE)" 3068704001_1 CDM 306 RC 87040 HCPCS outpatient 194 145.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 184.3 95 999999999 151.32 184.3 percent of total billed charges "CULTURE, BACTERIAL; BLOOD, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES (INCLUDES ANAEROBIC CULTURE, IF APPROPRIATE)" 3068704001_1 CDM 306 RC 87040 HCPCS outpatient 194 145.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 172.66 89 999999999 151.32 184.3 percent of total billed charges "CULTURE, BACTERIAL; BLOOD, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES (INCLUDES ANAEROBIC CULTURE, IF APPROPRIATE)" 3068704001_1 CDM 306 RC 87040 HCPCS outpatient 194 145.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 170.72 88 999999999 151.32 184.3 percent of total billed charges "CULTURE, BACTERIAL; BLOOD, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES (INCLUDES ANAEROBIC CULTURE, IF APPROPRIATE)" 3068704001_1 CDM 306 RC 87040 HCPCS outpatient 194 145.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 172.66 89 999999999 151.32 184.3 percent of total billed charges "CULTURE, BACTERIAL; STOOL, AEROBIC, WITH ISOLATION AND PRELIMINARY EXAMINATION (EG, KIA, LIA), SALMONELLA AND SHIGELLA SPECIES" 3068704501_1 CDM 306 RC 87045 HCPCS outpatient 100 75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 90 90 999999999 78 95 percent of total billed charges "CULTURE, BACTERIAL; STOOL, AEROBIC, WITH ISOLATION AND PRELIMINARY EXAMINATION (EG, KIA, LIA), SALMONELLA AND SHIGELLA SPECIES" 3068704501_1 CDM 306 RC 87045 HCPCS outpatient 100 75 AETNA MCR ADV AETNA MCR ADV 78 78 999999999 78 95 percent of total billed charges "CULTURE, BACTERIAL; STOOL, AEROBIC, WITH ISOLATION AND PRELIMINARY EXAMINATION (EG, KIA, LIA), SALMONELLA AND SHIGELLA SPECIES" 3068704501_1 CDM 306 RC 87045 HCPCS outpatient 100 75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 87.57 87.57 999999999 78 95 percent of total billed charges "CULTURE, BACTERIAL; STOOL, AEROBIC, WITH ISOLATION AND PRELIMINARY EXAMINATION (EG, KIA, LIA), SALMONELLA AND SHIGELLA SPECIES" 3068704501_1 CDM 306 RC 87045 HCPCS outpatient 100 75 COORDINATED CARE MCAID COORDINATED CARE MCAID 85.07 85.07 999999999 78 95 percent of total billed charges "CULTURE, BACTERIAL; STOOL, AEROBIC, WITH ISOLATION AND PRELIMINARY EXAMINATION (EG, KIA, LIA), SALMONELLA AND SHIGELLA SPECIES" 3068704501_1 CDM 306 RC 87045 HCPCS outpatient 100 75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 85.07 85.07 999999999 78 95 percent of total billed charges "CULTURE, BACTERIAL; STOOL, AEROBIC, WITH ISOLATION AND PRELIMINARY EXAMINATION (EG, KIA, LIA), SALMONELLA AND SHIGELLA SPECIES" 3068704501_1 CDM 306 RC 87045 HCPCS outpatient 100 75 MOLINA MCAID MOLINA MCAID 83.4 83.4 999999999 78 95 percent of total billed charges "CULTURE, BACTERIAL; STOOL, AEROBIC, WITH ISOLATION AND PRELIMINARY EXAMINATION (EG, KIA, LIA), SALMONELLA AND SHIGELLA SPECIES" 3068704501_1 CDM 306 RC 87045 HCPCS outpatient 100 75 MOLINA MCR ADV MOLINA MCR ADV 89 89 999999999 78 95 percent of total billed charges "CULTURE, BACTERIAL; STOOL, AEROBIC, WITH ISOLATION AND PRELIMINARY EXAMINATION (EG, KIA, LIA), SALMONELLA AND SHIGELLA SPECIES" 3068704501_1 CDM 306 RC 87045 HCPCS outpatient 100 75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 89 89 999999999 78 95 percent of total billed charges "CULTURE, BACTERIAL; STOOL, AEROBIC, WITH ISOLATION AND PRELIMINARY EXAMINATION (EG, KIA, LIA), SALMONELLA AND SHIGELLA SPECIES" 3068704501_1 CDM 306 RC 87045 HCPCS outpatient 100 75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 89 89 999999999 78 95 percent of total billed charges "CULTURE, BACTERIAL; STOOL, AEROBIC, WITH ISOLATION AND PRELIMINARY EXAMINATION (EG, KIA, LIA), SALMONELLA AND SHIGELLA SPECIES" 3068704501_1 CDM 306 RC 87045 HCPCS outpatient 100 75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 90 90 999999999 78 95 percent of total billed charges "CULTURE, BACTERIAL; STOOL, AEROBIC, WITH ISOLATION AND PRELIMINARY EXAMINATION (EG, KIA, LIA), SALMONELLA AND SHIGELLA SPECIES" 3068704501_1 CDM 306 RC 87045 HCPCS outpatient 100 75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 95 95 999999999 78 95 percent of total billed charges "CULTURE, BACTERIAL; STOOL, AEROBIC, WITH ISOLATION AND PRELIMINARY EXAMINATION (EG, KIA, LIA), SALMONELLA AND SHIGELLA SPECIES" 3068704501_1 CDM 306 RC 87045 HCPCS outpatient 100 75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 95 95 999999999 78 95 percent of total billed charges "CULTURE, BACTERIAL; STOOL, AEROBIC, WITH ISOLATION AND PRELIMINARY EXAMINATION (EG, KIA, LIA), SALMONELLA AND SHIGELLA SPECIES" 3068704501_1 CDM 306 RC 87045 HCPCS outpatient 100 75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 89 89 999999999 78 95 percent of total billed charges "CULTURE, BACTERIAL; STOOL, AEROBIC, WITH ISOLATION AND PRELIMINARY EXAMINATION (EG, KIA, LIA), SALMONELLA AND SHIGELLA SPECIES" 3068704501_1 CDM 306 RC 87045 HCPCS outpatient 100 75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 88 88 999999999 78 95 percent of total billed charges "CULTURE, BACTERIAL; STOOL, AEROBIC, WITH ISOLATION AND PRELIMINARY EXAMINATION (EG, KIA, LIA), SALMONELLA AND SHIGELLA SPECIES" 3068704501_1 CDM 306 RC 87045 HCPCS outpatient 100 75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 89 89 999999999 78 95 percent of total billed charges "CULTURE, BACTERIAL; STOOL, AEROBIC, ADDITIONAL PATHOGENS, ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES, EACH PLATE" 3068704601_1 CDM 306 RC 87046 HCPCS outpatient 39 29.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 35.1 90 999999999 30.42 37.05 percent of total billed charges "CULTURE, BACTERIAL; STOOL, AEROBIC, ADDITIONAL PATHOGENS, ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES, EACH PLATE" 3068704601_1 CDM 306 RC 87046 HCPCS outpatient 39 29.25 AETNA MCR ADV AETNA MCR ADV 30.42 78 999999999 30.42 37.05 percent of total billed charges "CULTURE, BACTERIAL; STOOL, AEROBIC, ADDITIONAL PATHOGENS, ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES, EACH PLATE" 3068704601_1 CDM 306 RC 87046 HCPCS outpatient 39 29.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 34.15 87.57 999999999 30.42 37.05 percent of total billed charges "CULTURE, BACTERIAL; STOOL, AEROBIC, ADDITIONAL PATHOGENS, ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES, EACH PLATE" 3068704601_1 CDM 306 RC 87046 HCPCS outpatient 39 29.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 33.18 85.07 999999999 30.42 37.05 percent of total billed charges "CULTURE, BACTERIAL; STOOL, AEROBIC, ADDITIONAL PATHOGENS, ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES, EACH PLATE" 3068704601_1 CDM 306 RC 87046 HCPCS outpatient 39 29.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 33.18 85.07 999999999 30.42 37.05 percent of total billed charges "CULTURE, BACTERIAL; STOOL, AEROBIC, ADDITIONAL PATHOGENS, ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES, EACH PLATE" 3068704601_1 CDM 306 RC 87046 HCPCS outpatient 39 29.25 MOLINA MCAID MOLINA MCAID 32.53 83.4 999999999 30.42 37.05 percent of total billed charges "CULTURE, BACTERIAL; STOOL, AEROBIC, ADDITIONAL PATHOGENS, ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES, EACH PLATE" 3068704601_1 CDM 306 RC 87046 HCPCS outpatient 39 29.25 MOLINA MCR ADV MOLINA MCR ADV 34.71 89 999999999 30.42 37.05 percent of total billed charges "CULTURE, BACTERIAL; STOOL, AEROBIC, ADDITIONAL PATHOGENS, ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES, EACH PLATE" 3068704601_1 CDM 306 RC 87046 HCPCS outpatient 39 29.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 34.71 89 999999999 30.42 37.05 percent of total billed charges "CULTURE, BACTERIAL; STOOL, AEROBIC, ADDITIONAL PATHOGENS, ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES, EACH PLATE" 3068704601_1 CDM 306 RC 87046 HCPCS outpatient 39 29.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 34.71 89 999999999 30.42 37.05 percent of total billed charges "CULTURE, BACTERIAL; STOOL, AEROBIC, ADDITIONAL PATHOGENS, ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES, EACH PLATE" 3068704601_1 CDM 306 RC 87046 HCPCS outpatient 39 29.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 35.1 90 999999999 30.42 37.05 percent of total billed charges "CULTURE, BACTERIAL; STOOL, AEROBIC, ADDITIONAL PATHOGENS, ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES, EACH PLATE" 3068704601_1 CDM 306 RC 87046 HCPCS outpatient 39 29.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 37.05 95 999999999 30.42 37.05 percent of total billed charges "CULTURE, BACTERIAL; STOOL, AEROBIC, ADDITIONAL PATHOGENS, ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES, EACH PLATE" 3068704601_1 CDM 306 RC 87046 HCPCS outpatient 39 29.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 37.05 95 999999999 30.42 37.05 percent of total billed charges "CULTURE, BACTERIAL; STOOL, AEROBIC, ADDITIONAL PATHOGENS, ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES, EACH PLATE" 3068704601_1 CDM 306 RC 87046 HCPCS outpatient 39 29.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 34.71 89 999999999 30.42 37.05 percent of total billed charges "CULTURE, BACTERIAL; STOOL, AEROBIC, ADDITIONAL PATHOGENS, ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES, EACH PLATE" 3068704601_1 CDM 306 RC 87046 HCPCS outpatient 39 29.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 34.32 88 999999999 30.42 37.05 percent of total billed charges "CULTURE, BACTERIAL; STOOL, AEROBIC, ADDITIONAL PATHOGENS, ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES, EACH PLATE" 3068704601_1 CDM 306 RC 87046 HCPCS outpatient 39 29.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 34.71 89 999999999 30.42 37.05 percent of total billed charges "CULTURE, BACTERIAL; ANY OTHER SOURCE EXCEPT URINE, BLOOD OR STOOL, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707004_1 CDM 306 RC 87070 HCPCS outpatient 124 93 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 111.6 90 999999999 96.72 117.8 percent of total billed charges "CULTURE, BACTERIAL; ANY OTHER SOURCE EXCEPT URINE, BLOOD OR STOOL, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707004_1 CDM 306 RC 87070 HCPCS outpatient 124 93 AETNA MCR ADV AETNA MCR ADV 96.72 78 999999999 96.72 117.8 percent of total billed charges "CULTURE, BACTERIAL; ANY OTHER SOURCE EXCEPT URINE, BLOOD OR STOOL, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707004_1 CDM 306 RC 87070 HCPCS outpatient 124 93 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 108.59 87.57 999999999 96.72 117.8 percent of total billed charges "CULTURE, BACTERIAL; ANY OTHER SOURCE EXCEPT URINE, BLOOD OR STOOL, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707004_1 CDM 306 RC 87070 HCPCS outpatient 124 93 COORDINATED CARE MCAID COORDINATED CARE MCAID 105.49 85.07 999999999 96.72 117.8 percent of total billed charges "CULTURE, BACTERIAL; ANY OTHER SOURCE EXCEPT URINE, BLOOD OR STOOL, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707004_1 CDM 306 RC 87070 HCPCS outpatient 124 93 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 105.49 85.07 999999999 96.72 117.8 percent of total billed charges "CULTURE, BACTERIAL; ANY OTHER SOURCE EXCEPT URINE, BLOOD OR STOOL, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707004_1 CDM 306 RC 87070 HCPCS outpatient 124 93 MOLINA MCAID MOLINA MCAID 103.42 83.4 999999999 96.72 117.8 percent of total billed charges "CULTURE, BACTERIAL; ANY OTHER SOURCE EXCEPT URINE, BLOOD OR STOOL, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707004_1 CDM 306 RC 87070 HCPCS outpatient 124 93 MOLINA MCR ADV MOLINA MCR ADV 110.36 89 999999999 96.72 117.8 percent of total billed charges "CULTURE, BACTERIAL; ANY OTHER SOURCE EXCEPT URINE, BLOOD OR STOOL, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707004_1 CDM 306 RC 87070 HCPCS outpatient 124 93 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 110.36 89 999999999 96.72 117.8 percent of total billed charges "CULTURE, BACTERIAL; ANY OTHER SOURCE EXCEPT URINE, BLOOD OR STOOL, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707004_1 CDM 306 RC 87070 HCPCS outpatient 124 93 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 110.36 89 999999999 96.72 117.8 percent of total billed charges "CULTURE, BACTERIAL; ANY OTHER SOURCE EXCEPT URINE, BLOOD OR STOOL, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707004_1 CDM 306 RC 87070 HCPCS outpatient 124 93 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 111.6 90 999999999 96.72 117.8 percent of total billed charges "CULTURE, BACTERIAL; ANY OTHER SOURCE EXCEPT URINE, BLOOD OR STOOL, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707004_1 CDM 306 RC 87070 HCPCS outpatient 124 93 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 117.8 95 999999999 96.72 117.8 percent of total billed charges "CULTURE, BACTERIAL; ANY OTHER SOURCE EXCEPT URINE, BLOOD OR STOOL, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707004_1 CDM 306 RC 87070 HCPCS outpatient 124 93 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 117.8 95 999999999 96.72 117.8 percent of total billed charges "CULTURE, BACTERIAL; ANY OTHER SOURCE EXCEPT URINE, BLOOD OR STOOL, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707004_1 CDM 306 RC 87070 HCPCS outpatient 124 93 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 110.36 89 999999999 96.72 117.8 percent of total billed charges "CULTURE, BACTERIAL; ANY OTHER SOURCE EXCEPT URINE, BLOOD OR STOOL, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707004_1 CDM 306 RC 87070 HCPCS outpatient 124 93 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 109.12 88 999999999 96.72 117.8 percent of total billed charges "CULTURE, BACTERIAL; ANY OTHER SOURCE EXCEPT URINE, BLOOD OR STOOL, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707004_1 CDM 306 RC 87070 HCPCS outpatient 124 93 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 110.36 89 999999999 96.72 117.8 percent of total billed charges "CULTURE, BACTERIAL; ANY OTHER SOURCE EXCEPT URINE, BLOOD OR STOOL, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707006_1 CDM 306 RC 87070 HCPCS outpatient 124 93 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 111.6 90 999999999 96.72 117.8 percent of total billed charges "CULTURE, BACTERIAL; ANY OTHER SOURCE EXCEPT URINE, BLOOD OR STOOL, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707006_1 CDM 306 RC 87070 HCPCS outpatient 124 93 AETNA MCR ADV AETNA MCR ADV 96.72 78 999999999 96.72 117.8 percent of total billed charges "CULTURE, BACTERIAL; ANY OTHER SOURCE EXCEPT URINE, BLOOD OR STOOL, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707006_1 CDM 306 RC 87070 HCPCS outpatient 124 93 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 108.59 87.57 999999999 96.72 117.8 percent of total billed charges "CULTURE, BACTERIAL; ANY OTHER SOURCE EXCEPT URINE, BLOOD OR STOOL, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707006_1 CDM 306 RC 87070 HCPCS outpatient 124 93 COORDINATED CARE MCAID COORDINATED CARE MCAID 105.49 85.07 999999999 96.72 117.8 percent of total billed charges "CULTURE, BACTERIAL; ANY OTHER SOURCE EXCEPT URINE, BLOOD OR STOOL, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707006_1 CDM 306 RC 87070 HCPCS outpatient 124 93 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 105.49 85.07 999999999 96.72 117.8 percent of total billed charges "CULTURE, BACTERIAL; ANY OTHER SOURCE EXCEPT URINE, BLOOD OR STOOL, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707006_1 CDM 306 RC 87070 HCPCS outpatient 124 93 MOLINA MCAID MOLINA MCAID 103.42 83.4 999999999 96.72 117.8 percent of total billed charges "CULTURE, BACTERIAL; ANY OTHER SOURCE EXCEPT URINE, BLOOD OR STOOL, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707006_1 CDM 306 RC 87070 HCPCS outpatient 124 93 MOLINA MCR ADV MOLINA MCR ADV 110.36 89 999999999 96.72 117.8 percent of total billed charges "CULTURE, BACTERIAL; ANY OTHER SOURCE EXCEPT URINE, BLOOD OR STOOL, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707006_1 CDM 306 RC 87070 HCPCS outpatient 124 93 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 110.36 89 999999999 96.72 117.8 percent of total billed charges "CULTURE, BACTERIAL; ANY OTHER SOURCE EXCEPT URINE, BLOOD OR STOOL, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707006_1 CDM 306 RC 87070 HCPCS outpatient 124 93 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 110.36 89 999999999 96.72 117.8 percent of total billed charges "CULTURE, BACTERIAL; ANY OTHER SOURCE EXCEPT URINE, BLOOD OR STOOL, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707006_1 CDM 306 RC 87070 HCPCS outpatient 124 93 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 111.6 90 999999999 96.72 117.8 percent of total billed charges "CULTURE, BACTERIAL; ANY OTHER SOURCE EXCEPT URINE, BLOOD OR STOOL, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707006_1 CDM 306 RC 87070 HCPCS outpatient 124 93 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 117.8 95 999999999 96.72 117.8 percent of total billed charges "CULTURE, BACTERIAL; ANY OTHER SOURCE EXCEPT URINE, BLOOD OR STOOL, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707006_1 CDM 306 RC 87070 HCPCS outpatient 124 93 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 117.8 95 999999999 96.72 117.8 percent of total billed charges "CULTURE, BACTERIAL; ANY OTHER SOURCE EXCEPT URINE, BLOOD OR STOOL, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707006_1 CDM 306 RC 87070 HCPCS outpatient 124 93 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 110.36 89 999999999 96.72 117.8 percent of total billed charges "CULTURE, BACTERIAL; ANY OTHER SOURCE EXCEPT URINE, BLOOD OR STOOL, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707006_1 CDM 306 RC 87070 HCPCS outpatient 124 93 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 109.12 88 999999999 96.72 117.8 percent of total billed charges "CULTURE, BACTERIAL; ANY OTHER SOURCE EXCEPT URINE, BLOOD OR STOOL, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707006_1 CDM 306 RC 87070 HCPCS outpatient 124 93 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 110.36 89 999999999 96.72 117.8 percent of total billed charges "CULTURE, BACTERIAL; ANY SOURCE, EXCEPT BLOOD, ANAEROBIC WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707501_1 CDM 306 RC 87075 HCPCS outpatient 136 102 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 122.4 90 999999999 106.08 129.2 percent of total billed charges "CULTURE, BACTERIAL; ANY SOURCE, EXCEPT BLOOD, ANAEROBIC WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707501_1 CDM 306 RC 87075 HCPCS outpatient 136 102 AETNA MCR ADV AETNA MCR ADV 106.08 78 999999999 106.08 129.2 percent of total billed charges "CULTURE, BACTERIAL; ANY SOURCE, EXCEPT BLOOD, ANAEROBIC WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707501_1 CDM 306 RC 87075 HCPCS outpatient 136 102 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 119.1 87.57 999999999 106.08 129.2 percent of total billed charges "CULTURE, BACTERIAL; ANY SOURCE, EXCEPT BLOOD, ANAEROBIC WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707501_1 CDM 306 RC 87075 HCPCS outpatient 136 102 COORDINATED CARE MCAID COORDINATED CARE MCAID 115.7 85.07 999999999 106.08 129.2 percent of total billed charges "CULTURE, BACTERIAL; ANY SOURCE, EXCEPT BLOOD, ANAEROBIC WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707501_1 CDM 306 RC 87075 HCPCS outpatient 136 102 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 115.7 85.07 999999999 106.08 129.2 percent of total billed charges "CULTURE, BACTERIAL; ANY SOURCE, EXCEPT BLOOD, ANAEROBIC WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707501_1 CDM 306 RC 87075 HCPCS outpatient 136 102 MOLINA MCAID MOLINA MCAID 113.42 83.4 999999999 106.08 129.2 percent of total billed charges "CULTURE, BACTERIAL; ANY SOURCE, EXCEPT BLOOD, ANAEROBIC WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707501_1 CDM 306 RC 87075 HCPCS outpatient 136 102 MOLINA MCR ADV MOLINA MCR ADV 121.04 89 999999999 106.08 129.2 percent of total billed charges "CULTURE, BACTERIAL; ANY SOURCE, EXCEPT BLOOD, ANAEROBIC WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707501_1 CDM 306 RC 87075 HCPCS outpatient 136 102 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 121.04 89 999999999 106.08 129.2 percent of total billed charges "CULTURE, BACTERIAL; ANY SOURCE, EXCEPT BLOOD, ANAEROBIC WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707501_1 CDM 306 RC 87075 HCPCS outpatient 136 102 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 121.04 89 999999999 106.08 129.2 percent of total billed charges "CULTURE, BACTERIAL; ANY SOURCE, EXCEPT BLOOD, ANAEROBIC WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707501_1 CDM 306 RC 87075 HCPCS outpatient 136 102 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 122.4 90 999999999 106.08 129.2 percent of total billed charges "CULTURE, BACTERIAL; ANY SOURCE, EXCEPT BLOOD, ANAEROBIC WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707501_1 CDM 306 RC 87075 HCPCS outpatient 136 102 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 129.2 95 999999999 106.08 129.2 percent of total billed charges "CULTURE, BACTERIAL; ANY SOURCE, EXCEPT BLOOD, ANAEROBIC WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707501_1 CDM 306 RC 87075 HCPCS outpatient 136 102 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 129.2 95 999999999 106.08 129.2 percent of total billed charges "CULTURE, BACTERIAL; ANY SOURCE, EXCEPT BLOOD, ANAEROBIC WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707501_1 CDM 306 RC 87075 HCPCS outpatient 136 102 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 121.04 89 999999999 106.08 129.2 percent of total billed charges "CULTURE, BACTERIAL; ANY SOURCE, EXCEPT BLOOD, ANAEROBIC WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707501_1 CDM 306 RC 87075 HCPCS outpatient 136 102 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 119.68 88 999999999 106.08 129.2 percent of total billed charges "CULTURE, BACTERIAL; ANY SOURCE, EXCEPT BLOOD, ANAEROBIC WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES" 3068707501_1 CDM 306 RC 87075 HCPCS outpatient 136 102 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 121.04 89 999999999 106.08 129.2 percent of total billed charges "CULTURE, BACTERIAL; AEROBIC ISOLATE, ADDITIONAL METHODS REQUIRED FOR DEFINITIVE IDENTIFICATION, EACH ISOLATE" 3068707701_1 CDM 306 RC 87077 HCPCS outpatient 90 67.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 81 90 999999999 70.2 85.5 percent of total billed charges "CULTURE, BACTERIAL; AEROBIC ISOLATE, ADDITIONAL METHODS REQUIRED FOR DEFINITIVE IDENTIFICATION, EACH ISOLATE" 3068707701_1 CDM 306 RC 87077 HCPCS outpatient 90 67.5 AETNA MCR ADV AETNA MCR ADV 70.2 78 999999999 70.2 85.5 percent of total billed charges "CULTURE, BACTERIAL; AEROBIC ISOLATE, ADDITIONAL METHODS REQUIRED FOR DEFINITIVE IDENTIFICATION, EACH ISOLATE" 3068707701_1 CDM 306 RC 87077 HCPCS outpatient 90 67.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 78.81 87.57 999999999 70.2 85.5 percent of total billed charges "CULTURE, BACTERIAL; AEROBIC ISOLATE, ADDITIONAL METHODS REQUIRED FOR DEFINITIVE IDENTIFICATION, EACH ISOLATE" 3068707701_1 CDM 306 RC 87077 HCPCS outpatient 90 67.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 76.56 85.07 999999999 70.2 85.5 percent of total billed charges "CULTURE, BACTERIAL; AEROBIC ISOLATE, ADDITIONAL METHODS REQUIRED FOR DEFINITIVE IDENTIFICATION, EACH ISOLATE" 3068707701_1 CDM 306 RC 87077 HCPCS outpatient 90 67.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 76.56 85.07 999999999 70.2 85.5 percent of total billed charges "CULTURE, BACTERIAL; AEROBIC ISOLATE, ADDITIONAL METHODS REQUIRED FOR DEFINITIVE IDENTIFICATION, EACH ISOLATE" 3068707701_1 CDM 306 RC 87077 HCPCS outpatient 90 67.5 MOLINA MCAID MOLINA MCAID 75.06 83.4 999999999 70.2 85.5 percent of total billed charges "CULTURE, BACTERIAL; AEROBIC ISOLATE, ADDITIONAL METHODS REQUIRED FOR DEFINITIVE IDENTIFICATION, EACH ISOLATE" 3068707701_1 CDM 306 RC 87077 HCPCS outpatient 90 67.5 MOLINA MCR ADV MOLINA MCR ADV 80.1 89 999999999 70.2 85.5 percent of total billed charges "CULTURE, BACTERIAL; AEROBIC ISOLATE, ADDITIONAL METHODS REQUIRED FOR DEFINITIVE IDENTIFICATION, EACH ISOLATE" 3068707701_1 CDM 306 RC 87077 HCPCS outpatient 90 67.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 80.1 89 999999999 70.2 85.5 percent of total billed charges "CULTURE, BACTERIAL; AEROBIC ISOLATE, ADDITIONAL METHODS REQUIRED FOR DEFINITIVE IDENTIFICATION, EACH ISOLATE" 3068707701_1 CDM 306 RC 87077 HCPCS outpatient 90 67.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 80.1 89 999999999 70.2 85.5 percent of total billed charges "CULTURE, BACTERIAL; AEROBIC ISOLATE, ADDITIONAL METHODS REQUIRED FOR DEFINITIVE IDENTIFICATION, EACH ISOLATE" 3068707701_1 CDM 306 RC 87077 HCPCS outpatient 90 67.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 81 90 999999999 70.2 85.5 percent of total billed charges "CULTURE, BACTERIAL; AEROBIC ISOLATE, ADDITIONAL METHODS REQUIRED FOR DEFINITIVE IDENTIFICATION, EACH ISOLATE" 3068707701_1 CDM 306 RC 87077 HCPCS outpatient 90 67.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 85.5 95 999999999 70.2 85.5 percent of total billed charges "CULTURE, BACTERIAL; AEROBIC ISOLATE, ADDITIONAL METHODS REQUIRED FOR DEFINITIVE IDENTIFICATION, EACH ISOLATE" 3068707701_1 CDM 306 RC 87077 HCPCS outpatient 90 67.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 85.5 95 999999999 70.2 85.5 percent of total billed charges "CULTURE, BACTERIAL; AEROBIC ISOLATE, ADDITIONAL METHODS REQUIRED FOR DEFINITIVE IDENTIFICATION, EACH ISOLATE" 3068707701_1 CDM 306 RC 87077 HCPCS outpatient 90 67.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 80.1 89 999999999 70.2 85.5 percent of total billed charges "CULTURE, BACTERIAL; AEROBIC ISOLATE, ADDITIONAL METHODS REQUIRED FOR DEFINITIVE IDENTIFICATION, EACH ISOLATE" 3068707701_1 CDM 306 RC 87077 HCPCS outpatient 90 67.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 79.2 88 999999999 70.2 85.5 percent of total billed charges "CULTURE, BACTERIAL; AEROBIC ISOLATE, ADDITIONAL METHODS REQUIRED FOR DEFINITIVE IDENTIFICATION, EACH ISOLATE" 3068707701_1 CDM 306 RC 87077 HCPCS outpatient 90 67.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 80.1 89 999999999 70.2 85.5 percent of total billed charges "CULTURE, PRESUMPTIVE, PATHOGENIC ORGANISMS, SCREENING ONLY" 3068708103_1 CDM 306 RC 87081 HCPCS outpatient 84 63 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 75.6 90 999999999 65.52 79.8 percent of total billed charges "CULTURE, PRESUMPTIVE, PATHOGENIC ORGANISMS, SCREENING ONLY" 3068708103_1 CDM 306 RC 87081 HCPCS outpatient 84 63 AETNA MCR ADV AETNA MCR ADV 65.52 78 999999999 65.52 79.8 percent of total billed charges "CULTURE, PRESUMPTIVE, PATHOGENIC ORGANISMS, SCREENING ONLY" 3068708103_1 CDM 306 RC 87081 HCPCS outpatient 84 63 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 73.56 87.57 999999999 65.52 79.8 percent of total billed charges "CULTURE, PRESUMPTIVE, PATHOGENIC ORGANISMS, SCREENING ONLY" 3068708103_1 CDM 306 RC 87081 HCPCS outpatient 84 63 COORDINATED CARE MCAID COORDINATED CARE MCAID 71.46 85.07 999999999 65.52 79.8 percent of total billed charges "CULTURE, PRESUMPTIVE, PATHOGENIC ORGANISMS, SCREENING ONLY" 3068708103_1 CDM 306 RC 87081 HCPCS outpatient 84 63 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 71.46 85.07 999999999 65.52 79.8 percent of total billed charges "CULTURE, PRESUMPTIVE, PATHOGENIC ORGANISMS, SCREENING ONLY" 3068708103_1 CDM 306 RC 87081 HCPCS outpatient 84 63 MOLINA MCAID MOLINA MCAID 70.06 83.4 999999999 65.52 79.8 percent of total billed charges "CULTURE, PRESUMPTIVE, PATHOGENIC ORGANISMS, SCREENING ONLY" 3068708103_1 CDM 306 RC 87081 HCPCS outpatient 84 63 MOLINA MCR ADV MOLINA MCR ADV 74.76 89 999999999 65.52 79.8 percent of total billed charges "CULTURE, PRESUMPTIVE, PATHOGENIC ORGANISMS, SCREENING ONLY" 3068708103_1 CDM 306 RC 87081 HCPCS outpatient 84 63 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 74.76 89 999999999 65.52 79.8 percent of total billed charges "CULTURE, PRESUMPTIVE, PATHOGENIC ORGANISMS, SCREENING ONLY" 3068708103_1 CDM 306 RC 87081 HCPCS outpatient 84 63 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 74.76 89 999999999 65.52 79.8 percent of total billed charges "CULTURE, PRESUMPTIVE, PATHOGENIC ORGANISMS, SCREENING ONLY" 3068708103_1 CDM 306 RC 87081 HCPCS outpatient 84 63 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 75.6 90 999999999 65.52 79.8 percent of total billed charges "CULTURE, PRESUMPTIVE, PATHOGENIC ORGANISMS, SCREENING ONLY" 3068708103_1 CDM 306 RC 87081 HCPCS outpatient 84 63 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 79.8 95 999999999 65.52 79.8 percent of total billed charges "CULTURE, PRESUMPTIVE, PATHOGENIC ORGANISMS, SCREENING ONLY" 3068708103_1 CDM 306 RC 87081 HCPCS outpatient 84 63 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 79.8 95 999999999 65.52 79.8 percent of total billed charges "CULTURE, PRESUMPTIVE, PATHOGENIC ORGANISMS, SCREENING ONLY" 3068708103_1 CDM 306 RC 87081 HCPCS outpatient 84 63 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 74.76 89 999999999 65.52 79.8 percent of total billed charges "CULTURE, PRESUMPTIVE, PATHOGENIC ORGANISMS, SCREENING ONLY" 3068708103_1 CDM 306 RC 87081 HCPCS outpatient 84 63 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 73.92 88 999999999 65.52 79.8 percent of total billed charges "CULTURE, PRESUMPTIVE, PATHOGENIC ORGANISMS, SCREENING ONLY" 3068708103_1 CDM 306 RC 87081 HCPCS outpatient 84 63 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 74.76 89 999999999 65.52 79.8 percent of total billed charges "CULTURE, BACTERIAL; QUANTITATIVE COLONY COUNT, URINE" 3068708601_1 CDM 306 RC 87086 HCPCS outpatient 98 73.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 88.2 90 999999999 76.44 93.1 percent of total billed charges "CULTURE, BACTERIAL; QUANTITATIVE COLONY COUNT, URINE" 3068708601_1 CDM 306 RC 87086 HCPCS outpatient 98 73.5 AETNA MCR ADV AETNA MCR ADV 76.44 78 999999999 76.44 93.1 percent of total billed charges "CULTURE, BACTERIAL; QUANTITATIVE COLONY COUNT, URINE" 3068708601_1 CDM 306 RC 87086 HCPCS outpatient 98 73.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 85.82 87.57 999999999 76.44 93.1 percent of total billed charges "CULTURE, BACTERIAL; QUANTITATIVE COLONY COUNT, URINE" 3068708601_1 CDM 306 RC 87086 HCPCS outpatient 98 73.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 83.37 85.07 999999999 76.44 93.1 percent of total billed charges "CULTURE, BACTERIAL; QUANTITATIVE COLONY COUNT, URINE" 3068708601_1 CDM 306 RC 87086 HCPCS outpatient 98 73.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 83.37 85.07 999999999 76.44 93.1 percent of total billed charges "CULTURE, BACTERIAL; QUANTITATIVE COLONY COUNT, URINE" 3068708601_1 CDM 306 RC 87086 HCPCS outpatient 98 73.5 MOLINA MCAID MOLINA MCAID 81.73 83.4 999999999 76.44 93.1 percent of total billed charges "CULTURE, BACTERIAL; QUANTITATIVE COLONY COUNT, URINE" 3068708601_1 CDM 306 RC 87086 HCPCS outpatient 98 73.5 MOLINA MCR ADV MOLINA MCR ADV 87.22 89 999999999 76.44 93.1 percent of total billed charges "CULTURE, BACTERIAL; QUANTITATIVE COLONY COUNT, URINE" 3068708601_1 CDM 306 RC 87086 HCPCS outpatient 98 73.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 87.22 89 999999999 76.44 93.1 percent of total billed charges "CULTURE, BACTERIAL; QUANTITATIVE COLONY COUNT, URINE" 3068708601_1 CDM 306 RC 87086 HCPCS outpatient 98 73.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 87.22 89 999999999 76.44 93.1 percent of total billed charges "CULTURE, BACTERIAL; QUANTITATIVE COLONY COUNT, URINE" 3068708601_1 CDM 306 RC 87086 HCPCS outpatient 98 73.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 88.2 90 999999999 76.44 93.1 percent of total billed charges "CULTURE, BACTERIAL; QUANTITATIVE COLONY COUNT, URINE" 3068708601_1 CDM 306 RC 87086 HCPCS outpatient 98 73.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 93.1 95 999999999 76.44 93.1 percent of total billed charges "CULTURE, BACTERIAL; QUANTITATIVE COLONY COUNT, URINE" 3068708601_1 CDM 306 RC 87086 HCPCS outpatient 98 73.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 93.1 95 999999999 76.44 93.1 percent of total billed charges "CULTURE, BACTERIAL; QUANTITATIVE COLONY COUNT, URINE" 3068708601_1 CDM 306 RC 87086 HCPCS outpatient 98 73.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 87.22 89 999999999 76.44 93.1 percent of total billed charges "CULTURE, BACTERIAL; QUANTITATIVE COLONY COUNT, URINE" 3068708601_1 CDM 306 RC 87086 HCPCS outpatient 98 73.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 86.24 88 999999999 76.44 93.1 percent of total billed charges "CULTURE, BACTERIAL; QUANTITATIVE COLONY COUNT, URINE" 3068708601_1 CDM 306 RC 87086 HCPCS outpatient 98 73.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 87.22 89 999999999 76.44 93.1 percent of total billed charges "CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE IDENTIFICATION OF ISOLATES; SKIN, HAIR, OR NAIL" 3068710101_1 CDM 306 RC 87101 HCPCS outpatient 114 85.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 102.6 90 999999999 88.92 108.3 percent of total billed charges "CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE IDENTIFICATION OF ISOLATES; SKIN, HAIR, OR NAIL" 3068710101_1 CDM 306 RC 87101 HCPCS outpatient 114 85.5 AETNA MCR ADV AETNA MCR ADV 88.92 78 999999999 88.92 108.3 percent of total billed charges "CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE IDENTIFICATION OF ISOLATES; SKIN, HAIR, OR NAIL" 3068710101_1 CDM 306 RC 87101 HCPCS outpatient 114 85.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 99.83 87.57 999999999 88.92 108.3 percent of total billed charges "CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE IDENTIFICATION OF ISOLATES; SKIN, HAIR, OR NAIL" 3068710101_1 CDM 306 RC 87101 HCPCS outpatient 114 85.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 96.98 85.07 999999999 88.92 108.3 percent of total billed charges "CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE IDENTIFICATION OF ISOLATES; SKIN, HAIR, OR NAIL" 3068710101_1 CDM 306 RC 87101 HCPCS outpatient 114 85.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 96.98 85.07 999999999 88.92 108.3 percent of total billed charges "CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE IDENTIFICATION OF ISOLATES; SKIN, HAIR, OR NAIL" 3068710101_1 CDM 306 RC 87101 HCPCS outpatient 114 85.5 MOLINA MCAID MOLINA MCAID 95.08 83.4 999999999 88.92 108.3 percent of total billed charges "CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE IDENTIFICATION OF ISOLATES; SKIN, HAIR, OR NAIL" 3068710101_1 CDM 306 RC 87101 HCPCS outpatient 114 85.5 MOLINA MCR ADV MOLINA MCR ADV 101.46 89 999999999 88.92 108.3 percent of total billed charges "CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE IDENTIFICATION OF ISOLATES; SKIN, HAIR, OR NAIL" 3068710101_1 CDM 306 RC 87101 HCPCS outpatient 114 85.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 101.46 89 999999999 88.92 108.3 percent of total billed charges "CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE IDENTIFICATION OF ISOLATES; SKIN, HAIR, OR NAIL" 3068710101_1 CDM 306 RC 87101 HCPCS outpatient 114 85.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 101.46 89 999999999 88.92 108.3 percent of total billed charges "CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE IDENTIFICATION OF ISOLATES; SKIN, HAIR, OR NAIL" 3068710101_1 CDM 306 RC 87101 HCPCS outpatient 114 85.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 102.6 90 999999999 88.92 108.3 percent of total billed charges "CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE IDENTIFICATION OF ISOLATES; SKIN, HAIR, OR NAIL" 3068710101_1 CDM 306 RC 87101 HCPCS outpatient 114 85.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 108.3 95 999999999 88.92 108.3 percent of total billed charges "CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE IDENTIFICATION OF ISOLATES; SKIN, HAIR, OR NAIL" 3068710101_1 CDM 306 RC 87101 HCPCS outpatient 114 85.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 108.3 95 999999999 88.92 108.3 percent of total billed charges "CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE IDENTIFICATION OF ISOLATES; SKIN, HAIR, OR NAIL" 3068710101_1 CDM 306 RC 87101 HCPCS outpatient 114 85.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 101.46 89 999999999 88.92 108.3 percent of total billed charges "CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE IDENTIFICATION OF ISOLATES; SKIN, HAIR, OR NAIL" 3068710101_1 CDM 306 RC 87101 HCPCS outpatient 114 85.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 100.32 88 999999999 88.92 108.3 percent of total billed charges "CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE IDENTIFICATION OF ISOLATES; SKIN, HAIR, OR NAIL" 3068710101_1 CDM 306 RC 87101 HCPCS outpatient 114 85.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 101.46 89 999999999 88.92 108.3 percent of total billed charges "CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE IDENTIFICATION OF ISOLATES; OTHER SOURCE (EXCEPT BLOOD)" 3068710201_1 CDM 306 RC 87102 HCPCS outpatient 122 91.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 109.8 90 999999999 95.16 115.9 percent of total billed charges "CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE IDENTIFICATION OF ISOLATES; OTHER SOURCE (EXCEPT BLOOD)" 3068710201_1 CDM 306 RC 87102 HCPCS outpatient 122 91.5 AETNA MCR ADV AETNA MCR ADV 95.16 78 999999999 95.16 115.9 percent of total billed charges "CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE IDENTIFICATION OF ISOLATES; OTHER SOURCE (EXCEPT BLOOD)" 3068710201_1 CDM 306 RC 87102 HCPCS outpatient 122 91.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 106.84 87.57 999999999 95.16 115.9 percent of total billed charges "CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE IDENTIFICATION OF ISOLATES; OTHER SOURCE (EXCEPT BLOOD)" 3068710201_1 CDM 306 RC 87102 HCPCS outpatient 122 91.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 103.79 85.07 999999999 95.16 115.9 percent of total billed charges "CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE IDENTIFICATION OF ISOLATES; OTHER SOURCE (EXCEPT BLOOD)" 3068710201_1 CDM 306 RC 87102 HCPCS outpatient 122 91.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 103.79 85.07 999999999 95.16 115.9 percent of total billed charges "CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE IDENTIFICATION OF ISOLATES; OTHER SOURCE (EXCEPT BLOOD)" 3068710201_1 CDM 306 RC 87102 HCPCS outpatient 122 91.5 MOLINA MCAID MOLINA MCAID 101.75 83.4 999999999 95.16 115.9 percent of total billed charges "CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE IDENTIFICATION OF ISOLATES; OTHER SOURCE (EXCEPT BLOOD)" 3068710201_1 CDM 306 RC 87102 HCPCS outpatient 122 91.5 MOLINA MCR ADV MOLINA MCR ADV 108.58 89 999999999 95.16 115.9 percent of total billed charges "CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE IDENTIFICATION OF ISOLATES; OTHER SOURCE (EXCEPT BLOOD)" 3068710201_1 CDM 306 RC 87102 HCPCS outpatient 122 91.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 108.58 89 999999999 95.16 115.9 percent of total billed charges "CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE IDENTIFICATION OF ISOLATES; OTHER SOURCE (EXCEPT BLOOD)" 3068710201_1 CDM 306 RC 87102 HCPCS outpatient 122 91.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 108.58 89 999999999 95.16 115.9 percent of total billed charges "CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE IDENTIFICATION OF ISOLATES; OTHER SOURCE (EXCEPT BLOOD)" 3068710201_1 CDM 306 RC 87102 HCPCS outpatient 122 91.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 109.8 90 999999999 95.16 115.9 percent of total billed charges "CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE IDENTIFICATION OF ISOLATES; OTHER SOURCE (EXCEPT BLOOD)" 3068710201_1 CDM 306 RC 87102 HCPCS outpatient 122 91.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 115.9 95 999999999 95.16 115.9 percent of total billed charges "CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE IDENTIFICATION OF ISOLATES; OTHER SOURCE (EXCEPT BLOOD)" 3068710201_1 CDM 306 RC 87102 HCPCS outpatient 122 91.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 115.9 95 999999999 95.16 115.9 percent of total billed charges "CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE IDENTIFICATION OF ISOLATES; OTHER SOURCE (EXCEPT BLOOD)" 3068710201_1 CDM 306 RC 87102 HCPCS outpatient 122 91.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 108.58 89 999999999 95.16 115.9 percent of total billed charges "CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE IDENTIFICATION OF ISOLATES; OTHER SOURCE (EXCEPT BLOOD)" 3068710201_1 CDM 306 RC 87102 HCPCS outpatient 122 91.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 107.36 88 999999999 95.16 115.9 percent of total billed charges "CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE IDENTIFICATION OF ISOLATES; OTHER SOURCE (EXCEPT BLOOD)" 3068710201_1 CDM 306 RC 87102 HCPCS outpatient 122 91.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 108.58 89 999999999 95.16 115.9 percent of total billed charges "CULTURE, FUNGI, DEFINITIVE IDENTIFICATION, EACH ORGANISM; YEAST" 3068710601_1 CDM 306 RC 87106 HCPCS outpatient 106 79.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 95.4 90 999999999 82.68 100.7 percent of total billed charges "CULTURE, FUNGI, DEFINITIVE IDENTIFICATION, EACH ORGANISM; YEAST" 3068710601_1 CDM 306 RC 87106 HCPCS outpatient 106 79.5 AETNA MCR ADV AETNA MCR ADV 82.68 78 999999999 82.68 100.7 percent of total billed charges "CULTURE, FUNGI, DEFINITIVE IDENTIFICATION, EACH ORGANISM; YEAST" 3068710601_1 CDM 306 RC 87106 HCPCS outpatient 106 79.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 92.82 87.57 999999999 82.68 100.7 percent of total billed charges "CULTURE, FUNGI, DEFINITIVE IDENTIFICATION, EACH ORGANISM; YEAST" 3068710601_1 CDM 306 RC 87106 HCPCS outpatient 106 79.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 90.17 85.07 999999999 82.68 100.7 percent of total billed charges "CULTURE, FUNGI, DEFINITIVE IDENTIFICATION, EACH ORGANISM; YEAST" 3068710601_1 CDM 306 RC 87106 HCPCS outpatient 106 79.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 90.17 85.07 999999999 82.68 100.7 percent of total billed charges "CULTURE, FUNGI, DEFINITIVE IDENTIFICATION, EACH ORGANISM; YEAST" 3068710601_1 CDM 306 RC 87106 HCPCS outpatient 106 79.5 MOLINA MCAID MOLINA MCAID 88.4 83.4 999999999 82.68 100.7 percent of total billed charges "CULTURE, FUNGI, DEFINITIVE IDENTIFICATION, EACH ORGANISM; YEAST" 3068710601_1 CDM 306 RC 87106 HCPCS outpatient 106 79.5 MOLINA MCR ADV MOLINA MCR ADV 94.34 89 999999999 82.68 100.7 percent of total billed charges "CULTURE, FUNGI, DEFINITIVE IDENTIFICATION, EACH ORGANISM; YEAST" 3068710601_1 CDM 306 RC 87106 HCPCS outpatient 106 79.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 94.34 89 999999999 82.68 100.7 percent of total billed charges "CULTURE, FUNGI, DEFINITIVE IDENTIFICATION, EACH ORGANISM; YEAST" 3068710601_1 CDM 306 RC 87106 HCPCS outpatient 106 79.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 94.34 89 999999999 82.68 100.7 percent of total billed charges "CULTURE, FUNGI, DEFINITIVE IDENTIFICATION, EACH ORGANISM; YEAST" 3068710601_1 CDM 306 RC 87106 HCPCS outpatient 106 79.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 95.4 90 999999999 82.68 100.7 percent of total billed charges "CULTURE, FUNGI, DEFINITIVE IDENTIFICATION, EACH ORGANISM; YEAST" 3068710601_1 CDM 306 RC 87106 HCPCS outpatient 106 79.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 100.7 95 999999999 82.68 100.7 percent of total billed charges "CULTURE, FUNGI, DEFINITIVE IDENTIFICATION, EACH ORGANISM; YEAST" 3068710601_1 CDM 306 RC 87106 HCPCS outpatient 106 79.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 100.7 95 999999999 82.68 100.7 percent of total billed charges "CULTURE, FUNGI, DEFINITIVE IDENTIFICATION, EACH ORGANISM; YEAST" 3068710601_1 CDM 306 RC 87106 HCPCS outpatient 106 79.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 94.34 89 999999999 82.68 100.7 percent of total billed charges "CULTURE, FUNGI, DEFINITIVE IDENTIFICATION, EACH ORGANISM; YEAST" 3068710601_1 CDM 306 RC 87106 HCPCS outpatient 106 79.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 93.28 88 999999999 82.68 100.7 percent of total billed charges "CULTURE, FUNGI, DEFINITIVE IDENTIFICATION, EACH ORGANISM; YEAST" 3068710601_1 CDM 306 RC 87106 HCPCS outpatient 106 79.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 94.34 89 999999999 82.68 100.7 percent of total billed charges "CULTURE, CHLAMYDIA, ANY SOURCE" 3068711001_1 CDM 306 RC 87110 HCPCS outpatient 204 153 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 183.6 90 999999999 159.12 193.8 percent of total billed charges "CULTURE, CHLAMYDIA, ANY SOURCE" 3068711001_1 CDM 306 RC 87110 HCPCS outpatient 204 153 AETNA MCR ADV AETNA MCR ADV 159.12 78 999999999 159.12 193.8 percent of total billed charges "CULTURE, CHLAMYDIA, ANY SOURCE" 3068711001_1 CDM 306 RC 87110 HCPCS outpatient 204 153 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 178.64 87.57 999999999 159.12 193.8 percent of total billed charges "CULTURE, CHLAMYDIA, ANY SOURCE" 3068711001_1 CDM 306 RC 87110 HCPCS outpatient 204 153 COORDINATED CARE MCAID COORDINATED CARE MCAID 173.54 85.07 999999999 159.12 193.8 percent of total billed charges "CULTURE, CHLAMYDIA, ANY SOURCE" 3068711001_1 CDM 306 RC 87110 HCPCS outpatient 204 153 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 173.54 85.07 999999999 159.12 193.8 percent of total billed charges "CULTURE, CHLAMYDIA, ANY SOURCE" 3068711001_1 CDM 306 RC 87110 HCPCS outpatient 204 153 MOLINA MCAID MOLINA MCAID 170.14 83.4 999999999 159.12 193.8 percent of total billed charges "CULTURE, CHLAMYDIA, ANY SOURCE" 3068711001_1 CDM 306 RC 87110 HCPCS outpatient 204 153 MOLINA MCR ADV MOLINA MCR ADV 181.56 89 999999999 159.12 193.8 percent of total billed charges "CULTURE, CHLAMYDIA, ANY SOURCE" 3068711001_1 CDM 306 RC 87110 HCPCS outpatient 204 153 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 181.56 89 999999999 159.12 193.8 percent of total billed charges "CULTURE, CHLAMYDIA, ANY SOURCE" 3068711001_1 CDM 306 RC 87110 HCPCS outpatient 204 153 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 181.56 89 999999999 159.12 193.8 percent of total billed charges "CULTURE, CHLAMYDIA, ANY SOURCE" 3068711001_1 CDM 306 RC 87110 HCPCS outpatient 204 153 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 183.6 90 999999999 159.12 193.8 percent of total billed charges "CULTURE, CHLAMYDIA, ANY SOURCE" 3068711001_1 CDM 306 RC 87110 HCPCS outpatient 204 153 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 193.8 95 999999999 159.12 193.8 percent of total billed charges "CULTURE, CHLAMYDIA, ANY SOURCE" 3068711001_1 CDM 306 RC 87110 HCPCS outpatient 204 153 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 193.8 95 999999999 159.12 193.8 percent of total billed charges "CULTURE, CHLAMYDIA, ANY SOURCE" 3068711001_1 CDM 306 RC 87110 HCPCS outpatient 204 153 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 181.56 89 999999999 159.12 193.8 percent of total billed charges "CULTURE, CHLAMYDIA, ANY SOURCE" 3068711001_1 CDM 306 RC 87110 HCPCS outpatient 204 153 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 179.52 88 999999999 159.12 193.8 percent of total billed charges "CULTURE, CHLAMYDIA, ANY SOURCE" 3068711001_1 CDM 306 RC 87110 HCPCS outpatient 204 153 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 181.56 89 999999999 159.12 193.8 percent of total billed charges "PINWORM EXAM (EG, CELLOPHANE TAPE PREP)" 3068717201_1 CDM 306 RC 87172 HCPCS outpatient 61 45.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 54.9 90 999999999 47.58 57.95 percent of total billed charges "PINWORM EXAM (EG, CELLOPHANE TAPE PREP)" 3068717201_1 CDM 306 RC 87172 HCPCS outpatient 61 45.75 AETNA MCR ADV AETNA MCR ADV 47.58 78 999999999 47.58 57.95 percent of total billed charges "PINWORM EXAM (EG, CELLOPHANE TAPE PREP)" 3068717201_1 CDM 306 RC 87172 HCPCS outpatient 61 45.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 53.42 87.57 999999999 47.58 57.95 percent of total billed charges "PINWORM EXAM (EG, CELLOPHANE TAPE PREP)" 3068717201_1 CDM 306 RC 87172 HCPCS outpatient 61 45.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 51.89 85.07 999999999 47.58 57.95 percent of total billed charges "PINWORM EXAM (EG, CELLOPHANE TAPE PREP)" 3068717201_1 CDM 306 RC 87172 HCPCS outpatient 61 45.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 51.89 85.07 999999999 47.58 57.95 percent of total billed charges "PINWORM EXAM (EG, CELLOPHANE TAPE PREP)" 3068717201_1 CDM 306 RC 87172 HCPCS outpatient 61 45.75 MOLINA MCAID MOLINA MCAID 50.87 83.4 999999999 47.58 57.95 percent of total billed charges "PINWORM EXAM (EG, CELLOPHANE TAPE PREP)" 3068717201_1 CDM 306 RC 87172 HCPCS outpatient 61 45.75 MOLINA MCR ADV MOLINA MCR ADV 54.29 89 999999999 47.58 57.95 percent of total billed charges "PINWORM EXAM (EG, CELLOPHANE TAPE PREP)" 3068717201_1 CDM 306 RC 87172 HCPCS outpatient 61 45.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 54.29 89 999999999 47.58 57.95 percent of total billed charges "PINWORM EXAM (EG, CELLOPHANE TAPE PREP)" 3068717201_1 CDM 306 RC 87172 HCPCS outpatient 61 45.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 54.29 89 999999999 47.58 57.95 percent of total billed charges "PINWORM EXAM (EG, CELLOPHANE TAPE PREP)" 3068717201_1 CDM 306 RC 87172 HCPCS outpatient 61 45.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 54.9 90 999999999 47.58 57.95 percent of total billed charges "PINWORM EXAM (EG, CELLOPHANE TAPE PREP)" 3068717201_1 CDM 306 RC 87172 HCPCS outpatient 61 45.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 57.95 95 999999999 47.58 57.95 percent of total billed charges "PINWORM EXAM (EG, CELLOPHANE TAPE PREP)" 3068717201_1 CDM 306 RC 87172 HCPCS outpatient 61 45.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 57.95 95 999999999 47.58 57.95 percent of total billed charges "PINWORM EXAM (EG, CELLOPHANE TAPE PREP)" 3068717201_1 CDM 306 RC 87172 HCPCS outpatient 61 45.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 54.29 89 999999999 47.58 57.95 percent of total billed charges "PINWORM EXAM (EG, CELLOPHANE TAPE PREP)" 3068717201_1 CDM 306 RC 87172 HCPCS outpatient 61 45.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 53.68 88 999999999 47.58 57.95 percent of total billed charges "PINWORM EXAM (EG, CELLOPHANE TAPE PREP)" 3068717201_1 CDM 306 RC 87172 HCPCS outpatient 61 45.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 54.29 89 999999999 47.58 57.95 percent of total billed charges "OVA AND PARASITES, DIRECT SMEARS, CONCENTRATION AND IDENTIFICATION" 3068717701_1 CDM 306 RC 87177 HCPCS outpatient 83 62.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 74.7 90 999999999 64.74 78.85 percent of total billed charges "OVA AND PARASITES, DIRECT SMEARS, CONCENTRATION AND IDENTIFICATION" 3068717701_1 CDM 306 RC 87177 HCPCS outpatient 83 62.25 AETNA MCR ADV AETNA MCR ADV 64.74 78 999999999 64.74 78.85 percent of total billed charges "OVA AND PARASITES, DIRECT SMEARS, CONCENTRATION AND IDENTIFICATION" 3068717701_1 CDM 306 RC 87177 HCPCS outpatient 83 62.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 72.68 87.57 999999999 64.74 78.85 percent of total billed charges "OVA AND PARASITES, DIRECT SMEARS, CONCENTRATION AND IDENTIFICATION" 3068717701_1 CDM 306 RC 87177 HCPCS outpatient 83 62.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 70.61 85.07 999999999 64.74 78.85 percent of total billed charges "OVA AND PARASITES, DIRECT SMEARS, CONCENTRATION AND IDENTIFICATION" 3068717701_1 CDM 306 RC 87177 HCPCS outpatient 83 62.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 70.61 85.07 999999999 64.74 78.85 percent of total billed charges "OVA AND PARASITES, DIRECT SMEARS, CONCENTRATION AND IDENTIFICATION" 3068717701_1 CDM 306 RC 87177 HCPCS outpatient 83 62.25 MOLINA MCAID MOLINA MCAID 69.22 83.4 999999999 64.74 78.85 percent of total billed charges "OVA AND PARASITES, DIRECT SMEARS, CONCENTRATION AND IDENTIFICATION" 3068717701_1 CDM 306 RC 87177 HCPCS outpatient 83 62.25 MOLINA MCR ADV MOLINA MCR ADV 73.87 89 999999999 64.74 78.85 percent of total billed charges "OVA AND PARASITES, DIRECT SMEARS, CONCENTRATION AND IDENTIFICATION" 3068717701_1 CDM 306 RC 87177 HCPCS outpatient 83 62.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 73.87 89 999999999 64.74 78.85 percent of total billed charges "OVA AND PARASITES, DIRECT SMEARS, CONCENTRATION AND IDENTIFICATION" 3068717701_1 CDM 306 RC 87177 HCPCS outpatient 83 62.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 73.87 89 999999999 64.74 78.85 percent of total billed charges "OVA AND PARASITES, DIRECT SMEARS, CONCENTRATION AND IDENTIFICATION" 3068717701_1 CDM 306 RC 87177 HCPCS outpatient 83 62.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 74.7 90 999999999 64.74 78.85 percent of total billed charges "OVA AND PARASITES, DIRECT SMEARS, CONCENTRATION AND IDENTIFICATION" 3068717701_1 CDM 306 RC 87177 HCPCS outpatient 83 62.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 78.85 95 999999999 64.74 78.85 percent of total billed charges "OVA AND PARASITES, DIRECT SMEARS, CONCENTRATION AND IDENTIFICATION" 3068717701_1 CDM 306 RC 87177 HCPCS outpatient 83 62.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 78.85 95 999999999 64.74 78.85 percent of total billed charges "OVA AND PARASITES, DIRECT SMEARS, CONCENTRATION AND IDENTIFICATION" 3068717701_1 CDM 306 RC 87177 HCPCS outpatient 83 62.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 73.87 89 999999999 64.74 78.85 percent of total billed charges "OVA AND PARASITES, DIRECT SMEARS, CONCENTRATION AND IDENTIFICATION" 3068717701_1 CDM 306 RC 87177 HCPCS outpatient 83 62.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 73.04 88 999999999 64.74 78.85 percent of total billed charges "OVA AND PARASITES, DIRECT SMEARS, CONCENTRATION AND IDENTIFICATION" 3068717701_1 CDM 306 RC 87177 HCPCS outpatient 83 62.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 73.87 89 999999999 64.74 78.85 percent of total billed charges "SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; DISK METHOD, PER PLATE (12 OR FEWER AGENTS)" 3068718401_1 CDM 306 RC 87184 HCPCS outpatient 28 21 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 25.2 90 999999999 21.84 26.6 percent of total billed charges "SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; DISK METHOD, PER PLATE (12 OR FEWER AGENTS)" 3068718401_1 CDM 306 RC 87184 HCPCS outpatient 28 21 AETNA MCR ADV AETNA MCR ADV 21.84 78 999999999 21.84 26.6 percent of total billed charges "SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; DISK METHOD, PER PLATE (12 OR FEWER AGENTS)" 3068718401_1 CDM 306 RC 87184 HCPCS outpatient 28 21 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 24.52 87.57 999999999 21.84 26.6 percent of total billed charges "SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; DISK METHOD, PER PLATE (12 OR FEWER AGENTS)" 3068718401_1 CDM 306 RC 87184 HCPCS outpatient 28 21 COORDINATED CARE MCAID COORDINATED CARE MCAID 23.82 85.07 999999999 21.84 26.6 percent of total billed charges "SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; DISK METHOD, PER PLATE (12 OR FEWER AGENTS)" 3068718401_1 CDM 306 RC 87184 HCPCS outpatient 28 21 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 23.82 85.07 999999999 21.84 26.6 percent of total billed charges "SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; DISK METHOD, PER PLATE (12 OR FEWER AGENTS)" 3068718401_1 CDM 306 RC 87184 HCPCS outpatient 28 21 MOLINA MCAID MOLINA MCAID 23.35 83.4 999999999 21.84 26.6 percent of total billed charges "SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; DISK METHOD, PER PLATE (12 OR FEWER AGENTS)" 3068718401_1 CDM 306 RC 87184 HCPCS outpatient 28 21 MOLINA MCR ADV MOLINA MCR ADV 24.92 89 999999999 21.84 26.6 percent of total billed charges "SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; DISK METHOD, PER PLATE (12 OR FEWER AGENTS)" 3068718401_1 CDM 306 RC 87184 HCPCS outpatient 28 21 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 24.92 89 999999999 21.84 26.6 percent of total billed charges "SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; DISK METHOD, PER PLATE (12 OR FEWER AGENTS)" 3068718401_1 CDM 306 RC 87184 HCPCS outpatient 28 21 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 24.92 89 999999999 21.84 26.6 percent of total billed charges "SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; DISK METHOD, PER PLATE (12 OR FEWER AGENTS)" 3068718401_1 CDM 306 RC 87184 HCPCS outpatient 28 21 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 25.2 90 999999999 21.84 26.6 percent of total billed charges "SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; DISK METHOD, PER PLATE (12 OR FEWER AGENTS)" 3068718401_1 CDM 306 RC 87184 HCPCS outpatient 28 21 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 26.6 95 999999999 21.84 26.6 percent of total billed charges "SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; DISK METHOD, PER PLATE (12 OR FEWER AGENTS)" 3068718401_1 CDM 306 RC 87184 HCPCS outpatient 28 21 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 26.6 95 999999999 21.84 26.6 percent of total billed charges "SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; DISK METHOD, PER PLATE (12 OR FEWER AGENTS)" 3068718401_1 CDM 306 RC 87184 HCPCS outpatient 28 21 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 24.92 89 999999999 21.84 26.6 percent of total billed charges "SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; DISK METHOD, PER PLATE (12 OR FEWER AGENTS)" 3068718401_1 CDM 306 RC 87184 HCPCS outpatient 28 21 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 24.64 88 999999999 21.84 26.6 percent of total billed charges "SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; DISK METHOD, PER PLATE (12 OR FEWER AGENTS)" 3068718401_1 CDM 306 RC 87184 HCPCS outpatient 28 21 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 24.92 89 999999999 21.84 26.6 percent of total billed charges "SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; MICRODILUTION OR AGAR DILUTION (MINIMUM INHIBITORY CONCENTRATION [MIC] OR BREAKPOINT), EACH MULTI-ANTIMICROBIAL, PER PLATE" 3068718601_1 CDM 306 RC 87186 HCPCS outpatient 102 76.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 91.8 90 999999999 79.56 96.9 percent of total billed charges "SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; MICRODILUTION OR AGAR DILUTION (MINIMUM INHIBITORY CONCENTRATION [MIC] OR BREAKPOINT), EACH MULTI-ANTIMICROBIAL, PER PLATE" 3068718601_1 CDM 306 RC 87186 HCPCS outpatient 102 76.5 AETNA MCR ADV AETNA MCR ADV 79.56 78 999999999 79.56 96.9 percent of total billed charges "SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; MICRODILUTION OR AGAR DILUTION (MINIMUM INHIBITORY CONCENTRATION [MIC] OR BREAKPOINT), EACH MULTI-ANTIMICROBIAL, PER PLATE" 3068718601_1 CDM 306 RC 87186 HCPCS outpatient 102 76.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 89.32 87.57 999999999 79.56 96.9 percent of total billed charges "SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; MICRODILUTION OR AGAR DILUTION (MINIMUM INHIBITORY CONCENTRATION [MIC] OR BREAKPOINT), EACH MULTI-ANTIMICROBIAL, PER PLATE" 3068718601_1 CDM 306 RC 87186 HCPCS outpatient 102 76.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 86.77 85.07 999999999 79.56 96.9 percent of total billed charges "SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; MICRODILUTION OR AGAR DILUTION (MINIMUM INHIBITORY CONCENTRATION [MIC] OR BREAKPOINT), EACH MULTI-ANTIMICROBIAL, PER PLATE" 3068718601_1 CDM 306 RC 87186 HCPCS outpatient 102 76.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 86.77 85.07 999999999 79.56 96.9 percent of total billed charges "SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; MICRODILUTION OR AGAR DILUTION (MINIMUM INHIBITORY CONCENTRATION [MIC] OR BREAKPOINT), EACH MULTI-ANTIMICROBIAL, PER PLATE" 3068718601_1 CDM 306 RC 87186 HCPCS outpatient 102 76.5 MOLINA MCAID MOLINA MCAID 85.07 83.4 999999999 79.56 96.9 percent of total billed charges "SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; MICRODILUTION OR AGAR DILUTION (MINIMUM INHIBITORY CONCENTRATION [MIC] OR BREAKPOINT), EACH MULTI-ANTIMICROBIAL, PER PLATE" 3068718601_1 CDM 306 RC 87186 HCPCS outpatient 102 76.5 MOLINA MCR ADV MOLINA MCR ADV 90.78 89 999999999 79.56 96.9 percent of total billed charges "SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; MICRODILUTION OR AGAR DILUTION (MINIMUM INHIBITORY CONCENTRATION [MIC] OR BREAKPOINT), EACH MULTI-ANTIMICROBIAL, PER PLATE" 3068718601_1 CDM 306 RC 87186 HCPCS outpatient 102 76.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 90.78 89 999999999 79.56 96.9 percent of total billed charges "SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; MICRODILUTION OR AGAR DILUTION (MINIMUM INHIBITORY CONCENTRATION [MIC] OR BREAKPOINT), EACH MULTI-ANTIMICROBIAL, PER PLATE" 3068718601_1 CDM 306 RC 87186 HCPCS outpatient 102 76.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 90.78 89 999999999 79.56 96.9 percent of total billed charges "SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; MICRODILUTION OR AGAR DILUTION (MINIMUM INHIBITORY CONCENTRATION [MIC] OR BREAKPOINT), EACH MULTI-ANTIMICROBIAL, PER PLATE" 3068718601_1 CDM 306 RC 87186 HCPCS outpatient 102 76.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 91.8 90 999999999 79.56 96.9 percent of total billed charges "SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; MICRODILUTION OR AGAR DILUTION (MINIMUM INHIBITORY CONCENTRATION [MIC] OR BREAKPOINT), EACH MULTI-ANTIMICROBIAL, PER PLATE" 3068718601_1 CDM 306 RC 87186 HCPCS outpatient 102 76.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 96.9 95 999999999 79.56 96.9 percent of total billed charges "SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; MICRODILUTION OR AGAR DILUTION (MINIMUM INHIBITORY CONCENTRATION [MIC] OR BREAKPOINT), EACH MULTI-ANTIMICROBIAL, PER PLATE" 3068718601_1 CDM 306 RC 87186 HCPCS outpatient 102 76.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 96.9 95 999999999 79.56 96.9 percent of total billed charges "SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; MICRODILUTION OR AGAR DILUTION (MINIMUM INHIBITORY CONCENTRATION [MIC] OR BREAKPOINT), EACH MULTI-ANTIMICROBIAL, PER PLATE" 3068718601_1 CDM 306 RC 87186 HCPCS outpatient 102 76.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 90.78 89 999999999 79.56 96.9 percent of total billed charges "SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; MICRODILUTION OR AGAR DILUTION (MINIMUM INHIBITORY CONCENTRATION [MIC] OR BREAKPOINT), EACH MULTI-ANTIMICROBIAL, PER PLATE" 3068718601_1 CDM 306 RC 87186 HCPCS outpatient 102 76.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 89.76 88 999999999 79.56 96.9 percent of total billed charges "SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; MICRODILUTION OR AGAR DILUTION (MINIMUM INHIBITORY CONCENTRATION [MIC] OR BREAKPOINT), EACH MULTI-ANTIMICROBIAL, PER PLATE" 3068718601_1 CDM 306 RC 87186 HCPCS outpatient 102 76.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 90.78 89 999999999 79.56 96.9 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; GRAM OR GIEMSA STAIN FOR BACTERIA, FUNGI, OR CELL TYPES" 3068720502_1 CDM 306 RC 87205 HCPCS outpatient 77 57.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 69.3 90 999999999 60.06 73.15 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; GRAM OR GIEMSA STAIN FOR BACTERIA, FUNGI, OR CELL TYPES" 3068720502_1 CDM 306 RC 87205 HCPCS outpatient 77 57.75 AETNA MCR ADV AETNA MCR ADV 60.06 78 999999999 60.06 73.15 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; GRAM OR GIEMSA STAIN FOR BACTERIA, FUNGI, OR CELL TYPES" 3068720502_1 CDM 306 RC 87205 HCPCS outpatient 77 57.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 67.43 87.57 999999999 60.06 73.15 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; GRAM OR GIEMSA STAIN FOR BACTERIA, FUNGI, OR CELL TYPES" 3068720502_1 CDM 306 RC 87205 HCPCS outpatient 77 57.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 65.5 85.07 999999999 60.06 73.15 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; GRAM OR GIEMSA STAIN FOR BACTERIA, FUNGI, OR CELL TYPES" 3068720502_1 CDM 306 RC 87205 HCPCS outpatient 77 57.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 65.5 85.07 999999999 60.06 73.15 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; GRAM OR GIEMSA STAIN FOR BACTERIA, FUNGI, OR CELL TYPES" 3068720502_1 CDM 306 RC 87205 HCPCS outpatient 77 57.75 MOLINA MCAID MOLINA MCAID 64.22 83.4 999999999 60.06 73.15 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; GRAM OR GIEMSA STAIN FOR BACTERIA, FUNGI, OR CELL TYPES" 3068720502_1 CDM 306 RC 87205 HCPCS outpatient 77 57.75 MOLINA MCR ADV MOLINA MCR ADV 68.53 89 999999999 60.06 73.15 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; GRAM OR GIEMSA STAIN FOR BACTERIA, FUNGI, OR CELL TYPES" 3068720502_1 CDM 306 RC 87205 HCPCS outpatient 77 57.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 68.53 89 999999999 60.06 73.15 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; GRAM OR GIEMSA STAIN FOR BACTERIA, FUNGI, OR CELL TYPES" 3068720502_1 CDM 306 RC 87205 HCPCS outpatient 77 57.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 68.53 89 999999999 60.06 73.15 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; GRAM OR GIEMSA STAIN FOR BACTERIA, FUNGI, OR CELL TYPES" 3068720502_1 CDM 306 RC 87205 HCPCS outpatient 77 57.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 69.3 90 999999999 60.06 73.15 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; GRAM OR GIEMSA STAIN FOR BACTERIA, FUNGI, OR CELL TYPES" 3068720502_1 CDM 306 RC 87205 HCPCS outpatient 77 57.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 73.15 95 999999999 60.06 73.15 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; GRAM OR GIEMSA STAIN FOR BACTERIA, FUNGI, OR CELL TYPES" 3068720502_1 CDM 306 RC 87205 HCPCS outpatient 77 57.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 73.15 95 999999999 60.06 73.15 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; GRAM OR GIEMSA STAIN FOR BACTERIA, FUNGI, OR CELL TYPES" 3068720502_1 CDM 306 RC 87205 HCPCS outpatient 77 57.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 68.53 89 999999999 60.06 73.15 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; GRAM OR GIEMSA STAIN FOR BACTERIA, FUNGI, OR CELL TYPES" 3068720502_1 CDM 306 RC 87205 HCPCS outpatient 77 57.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 67.76 88 999999999 60.06 73.15 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; GRAM OR GIEMSA STAIN FOR BACTERIA, FUNGI, OR CELL TYPES" 3068720502_1 CDM 306 RC 87205 HCPCS outpatient 77 57.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 68.53 89 999999999 60.06 73.15 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; FLUORESCENT AND/OR ACID FAST STAIN FOR BACTERIA, FUNGI, PARASITES, VIRUSES OR CELL TYPES" 3068720605_1 CDM 306 RC 87206 HCPCS outpatient 77 57.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 69.3 90 999999999 60.06 73.15 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; FLUORESCENT AND/OR ACID FAST STAIN FOR BACTERIA, FUNGI, PARASITES, VIRUSES OR CELL TYPES" 3068720605_1 CDM 306 RC 87206 HCPCS outpatient 77 57.75 AETNA MCR ADV AETNA MCR ADV 60.06 78 999999999 60.06 73.15 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; FLUORESCENT AND/OR ACID FAST STAIN FOR BACTERIA, FUNGI, PARASITES, VIRUSES OR CELL TYPES" 3068720605_1 CDM 306 RC 87206 HCPCS outpatient 77 57.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 67.43 87.57 999999999 60.06 73.15 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; FLUORESCENT AND/OR ACID FAST STAIN FOR BACTERIA, FUNGI, PARASITES, VIRUSES OR CELL TYPES" 3068720605_1 CDM 306 RC 87206 HCPCS outpatient 77 57.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 65.5 85.07 999999999 60.06 73.15 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; FLUORESCENT AND/OR ACID FAST STAIN FOR BACTERIA, FUNGI, PARASITES, VIRUSES OR CELL TYPES" 3068720605_1 CDM 306 RC 87206 HCPCS outpatient 77 57.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 65.5 85.07 999999999 60.06 73.15 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; FLUORESCENT AND/OR ACID FAST STAIN FOR BACTERIA, FUNGI, PARASITES, VIRUSES OR CELL TYPES" 3068720605_1 CDM 306 RC 87206 HCPCS outpatient 77 57.75 MOLINA MCAID MOLINA MCAID 64.22 83.4 999999999 60.06 73.15 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; FLUORESCENT AND/OR ACID FAST STAIN FOR BACTERIA, FUNGI, PARASITES, VIRUSES OR CELL TYPES" 3068720605_1 CDM 306 RC 87206 HCPCS outpatient 77 57.75 MOLINA MCR ADV MOLINA MCR ADV 68.53 89 999999999 60.06 73.15 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; FLUORESCENT AND/OR ACID FAST STAIN FOR BACTERIA, FUNGI, PARASITES, VIRUSES OR CELL TYPES" 3068720605_1 CDM 306 RC 87206 HCPCS outpatient 77 57.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 68.53 89 999999999 60.06 73.15 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; FLUORESCENT AND/OR ACID FAST STAIN FOR BACTERIA, FUNGI, PARASITES, VIRUSES OR CELL TYPES" 3068720605_1 CDM 306 RC 87206 HCPCS outpatient 77 57.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 68.53 89 999999999 60.06 73.15 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; FLUORESCENT AND/OR ACID FAST STAIN FOR BACTERIA, FUNGI, PARASITES, VIRUSES OR CELL TYPES" 3068720605_1 CDM 306 RC 87206 HCPCS outpatient 77 57.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 69.3 90 999999999 60.06 73.15 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; FLUORESCENT AND/OR ACID FAST STAIN FOR BACTERIA, FUNGI, PARASITES, VIRUSES OR CELL TYPES" 3068720605_1 CDM 306 RC 87206 HCPCS outpatient 77 57.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 73.15 95 999999999 60.06 73.15 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; FLUORESCENT AND/OR ACID FAST STAIN FOR BACTERIA, FUNGI, PARASITES, VIRUSES OR CELL TYPES" 3068720605_1 CDM 306 RC 87206 HCPCS outpatient 77 57.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 73.15 95 999999999 60.06 73.15 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; FLUORESCENT AND/OR ACID FAST STAIN FOR BACTERIA, FUNGI, PARASITES, VIRUSES OR CELL TYPES" 3068720605_1 CDM 306 RC 87206 HCPCS outpatient 77 57.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 68.53 89 999999999 60.06 73.15 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; FLUORESCENT AND/OR ACID FAST STAIN FOR BACTERIA, FUNGI, PARASITES, VIRUSES OR CELL TYPES" 3068720605_1 CDM 306 RC 87206 HCPCS outpatient 77 57.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 67.76 88 999999999 60.06 73.15 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; FLUORESCENT AND/OR ACID FAST STAIN FOR BACTERIA, FUNGI, PARASITES, VIRUSES OR CELL TYPES" 3068720605_1 CDM 306 RC 87206 HCPCS outpatient 77 57.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 68.53 89 999999999 60.06 73.15 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; SPECIAL STAIN FOR INCLUSION BODIES OR PARASITES (EG, MALARIA, COCCIDIA, MICROSPORIDIA, TRYPANOSOMES, HERPES VIRUSES)" 3068720701_1 CDM 306 RC 87207 HCPCS outpatient 79 59.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 71.1 90 999999999 61.62 75.05 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; SPECIAL STAIN FOR INCLUSION BODIES OR PARASITES (EG, MALARIA, COCCIDIA, MICROSPORIDIA, TRYPANOSOMES, HERPES VIRUSES)" 3068720701_1 CDM 306 RC 87207 HCPCS outpatient 79 59.25 AETNA MCR ADV AETNA MCR ADV 61.62 78 999999999 61.62 75.05 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; SPECIAL STAIN FOR INCLUSION BODIES OR PARASITES (EG, MALARIA, COCCIDIA, MICROSPORIDIA, TRYPANOSOMES, HERPES VIRUSES)" 3068720701_1 CDM 306 RC 87207 HCPCS outpatient 79 59.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 69.18 87.57 999999999 61.62 75.05 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; SPECIAL STAIN FOR INCLUSION BODIES OR PARASITES (EG, MALARIA, COCCIDIA, MICROSPORIDIA, TRYPANOSOMES, HERPES VIRUSES)" 3068720701_1 CDM 306 RC 87207 HCPCS outpatient 79 59.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 67.21 85.07 999999999 61.62 75.05 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; SPECIAL STAIN FOR INCLUSION BODIES OR PARASITES (EG, MALARIA, COCCIDIA, MICROSPORIDIA, TRYPANOSOMES, HERPES VIRUSES)" 3068720701_1 CDM 306 RC 87207 HCPCS outpatient 79 59.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 67.21 85.07 999999999 61.62 75.05 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; SPECIAL STAIN FOR INCLUSION BODIES OR PARASITES (EG, MALARIA, COCCIDIA, MICROSPORIDIA, TRYPANOSOMES, HERPES VIRUSES)" 3068720701_1 CDM 306 RC 87207 HCPCS outpatient 79 59.25 MOLINA MCAID MOLINA MCAID 65.89 83.4 999999999 61.62 75.05 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; SPECIAL STAIN FOR INCLUSION BODIES OR PARASITES (EG, MALARIA, COCCIDIA, MICROSPORIDIA, TRYPANOSOMES, HERPES VIRUSES)" 3068720701_1 CDM 306 RC 87207 HCPCS outpatient 79 59.25 MOLINA MCR ADV MOLINA MCR ADV 70.31 89 999999999 61.62 75.05 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; SPECIAL STAIN FOR INCLUSION BODIES OR PARASITES (EG, MALARIA, COCCIDIA, MICROSPORIDIA, TRYPANOSOMES, HERPES VIRUSES)" 3068720701_1 CDM 306 RC 87207 HCPCS outpatient 79 59.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 70.31 89 999999999 61.62 75.05 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; SPECIAL STAIN FOR INCLUSION BODIES OR PARASITES (EG, MALARIA, COCCIDIA, MICROSPORIDIA, TRYPANOSOMES, HERPES VIRUSES)" 3068720701_1 CDM 306 RC 87207 HCPCS outpatient 79 59.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 70.31 89 999999999 61.62 75.05 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; SPECIAL STAIN FOR INCLUSION BODIES OR PARASITES (EG, MALARIA, COCCIDIA, MICROSPORIDIA, TRYPANOSOMES, HERPES VIRUSES)" 3068720701_1 CDM 306 RC 87207 HCPCS outpatient 79 59.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 71.1 90 999999999 61.62 75.05 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; SPECIAL STAIN FOR INCLUSION BODIES OR PARASITES (EG, MALARIA, COCCIDIA, MICROSPORIDIA, TRYPANOSOMES, HERPES VIRUSES)" 3068720701_1 CDM 306 RC 87207 HCPCS outpatient 79 59.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 75.05 95 999999999 61.62 75.05 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; SPECIAL STAIN FOR INCLUSION BODIES OR PARASITES (EG, MALARIA, COCCIDIA, MICROSPORIDIA, TRYPANOSOMES, HERPES VIRUSES)" 3068720701_1 CDM 306 RC 87207 HCPCS outpatient 79 59.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 75.05 95 999999999 61.62 75.05 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; SPECIAL STAIN FOR INCLUSION BODIES OR PARASITES (EG, MALARIA, COCCIDIA, MICROSPORIDIA, TRYPANOSOMES, HERPES VIRUSES)" 3068720701_1 CDM 306 RC 87207 HCPCS outpatient 79 59.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 70.31 89 999999999 61.62 75.05 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; SPECIAL STAIN FOR INCLUSION BODIES OR PARASITES (EG, MALARIA, COCCIDIA, MICROSPORIDIA, TRYPANOSOMES, HERPES VIRUSES)" 3068720701_1 CDM 306 RC 87207 HCPCS outpatient 79 59.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 69.52 88 999999999 61.62 75.05 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; SPECIAL STAIN FOR INCLUSION BODIES OR PARASITES (EG, MALARIA, COCCIDIA, MICROSPORIDIA, TRYPANOSOMES, HERPES VIRUSES)" 3068720701_1 CDM 306 RC 87207 HCPCS outpatient 79 59.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 70.31 89 999999999 61.62 75.05 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; COMPLEX SPECIAL STAIN (EG, TRICHROME, IRON HEMOTOXYLIN) FOR OVA AND PARASITES" 3068720901_1 CDM 306 RC 87209 HCPCS outpatient 107 80.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 96.3 90 999999999 83.46 101.65 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; COMPLEX SPECIAL STAIN (EG, TRICHROME, IRON HEMOTOXYLIN) FOR OVA AND PARASITES" 3068720901_1 CDM 306 RC 87209 HCPCS outpatient 107 80.25 AETNA MCR ADV AETNA MCR ADV 83.46 78 999999999 83.46 101.65 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; COMPLEX SPECIAL STAIN (EG, TRICHROME, IRON HEMOTOXYLIN) FOR OVA AND PARASITES" 3068720901_1 CDM 306 RC 87209 HCPCS outpatient 107 80.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 93.7 87.57 999999999 83.46 101.65 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; COMPLEX SPECIAL STAIN (EG, TRICHROME, IRON HEMOTOXYLIN) FOR OVA AND PARASITES" 3068720901_1 CDM 306 RC 87209 HCPCS outpatient 107 80.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 91.02 85.07 999999999 83.46 101.65 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; COMPLEX SPECIAL STAIN (EG, TRICHROME, IRON HEMOTOXYLIN) FOR OVA AND PARASITES" 3068720901_1 CDM 306 RC 87209 HCPCS outpatient 107 80.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 91.02 85.07 999999999 83.46 101.65 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; COMPLEX SPECIAL STAIN (EG, TRICHROME, IRON HEMOTOXYLIN) FOR OVA AND PARASITES" 3068720901_1 CDM 306 RC 87209 HCPCS outpatient 107 80.25 MOLINA MCAID MOLINA MCAID 89.24 83.4 999999999 83.46 101.65 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; COMPLEX SPECIAL STAIN (EG, TRICHROME, IRON HEMOTOXYLIN) FOR OVA AND PARASITES" 3068720901_1 CDM 306 RC 87209 HCPCS outpatient 107 80.25 MOLINA MCR ADV MOLINA MCR ADV 95.23 89 999999999 83.46 101.65 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; COMPLEX SPECIAL STAIN (EG, TRICHROME, IRON HEMOTOXYLIN) FOR OVA AND PARASITES" 3068720901_1 CDM 306 RC 87209 HCPCS outpatient 107 80.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 95.23 89 999999999 83.46 101.65 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; COMPLEX SPECIAL STAIN (EG, TRICHROME, IRON HEMOTOXYLIN) FOR OVA AND PARASITES" 3068720901_1 CDM 306 RC 87209 HCPCS outpatient 107 80.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 95.23 89 999999999 83.46 101.65 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; COMPLEX SPECIAL STAIN (EG, TRICHROME, IRON HEMOTOXYLIN) FOR OVA AND PARASITES" 3068720901_1 CDM 306 RC 87209 HCPCS outpatient 107 80.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 96.3 90 999999999 83.46 101.65 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; COMPLEX SPECIAL STAIN (EG, TRICHROME, IRON HEMOTOXYLIN) FOR OVA AND PARASITES" 3068720901_1 CDM 306 RC 87209 HCPCS outpatient 107 80.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 101.65 95 999999999 83.46 101.65 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; COMPLEX SPECIAL STAIN (EG, TRICHROME, IRON HEMOTOXYLIN) FOR OVA AND PARASITES" 3068720901_1 CDM 306 RC 87209 HCPCS outpatient 107 80.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 101.65 95 999999999 83.46 101.65 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; COMPLEX SPECIAL STAIN (EG, TRICHROME, IRON HEMOTOXYLIN) FOR OVA AND PARASITES" 3068720901_1 CDM 306 RC 87209 HCPCS outpatient 107 80.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 95.23 89 999999999 83.46 101.65 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; COMPLEX SPECIAL STAIN (EG, TRICHROME, IRON HEMOTOXYLIN) FOR OVA AND PARASITES" 3068720901_1 CDM 306 RC 87209 HCPCS outpatient 107 80.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 94.16 88 999999999 83.46 101.65 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; COMPLEX SPECIAL STAIN (EG, TRICHROME, IRON HEMOTOXYLIN) FOR OVA AND PARASITES" 3068720901_1 CDM 306 RC 87209 HCPCS outpatient 107 80.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 95.23 89 999999999 83.46 101.65 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; WET MOUNT FOR INFECTIOUS AGENTS (EG, SALINE, INDIA INK, KOH PREPS)" 3068721001_1 CDM 306 RC 87210 HCPCS outpatient 84 63 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 75.6 90 999999999 65.52 79.8 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; WET MOUNT FOR INFECTIOUS AGENTS (EG, SALINE, INDIA INK, KOH PREPS)" 3068721001_1 CDM 306 RC 87210 HCPCS outpatient 84 63 AETNA MCR ADV AETNA MCR ADV 65.52 78 999999999 65.52 79.8 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; WET MOUNT FOR INFECTIOUS AGENTS (EG, SALINE, INDIA INK, KOH PREPS)" 3068721001_1 CDM 306 RC 87210 HCPCS outpatient 84 63 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 73.56 87.57 999999999 65.52 79.8 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; WET MOUNT FOR INFECTIOUS AGENTS (EG, SALINE, INDIA INK, KOH PREPS)" 3068721001_1 CDM 306 RC 87210 HCPCS outpatient 84 63 COORDINATED CARE MCAID COORDINATED CARE MCAID 71.46 85.07 999999999 65.52 79.8 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; WET MOUNT FOR INFECTIOUS AGENTS (EG, SALINE, INDIA INK, KOH PREPS)" 3068721001_1 CDM 306 RC 87210 HCPCS outpatient 84 63 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 71.46 85.07 999999999 65.52 79.8 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; WET MOUNT FOR INFECTIOUS AGENTS (EG, SALINE, INDIA INK, KOH PREPS)" 3068721001_1 CDM 306 RC 87210 HCPCS outpatient 84 63 MOLINA MCAID MOLINA MCAID 70.06 83.4 999999999 65.52 79.8 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; WET MOUNT FOR INFECTIOUS AGENTS (EG, SALINE, INDIA INK, KOH PREPS)" 3068721001_1 CDM 306 RC 87210 HCPCS outpatient 84 63 MOLINA MCR ADV MOLINA MCR ADV 74.76 89 999999999 65.52 79.8 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; WET MOUNT FOR INFECTIOUS AGENTS (EG, SALINE, INDIA INK, KOH PREPS)" 3068721001_1 CDM 306 RC 87210 HCPCS outpatient 84 63 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 74.76 89 999999999 65.52 79.8 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; WET MOUNT FOR INFECTIOUS AGENTS (EG, SALINE, INDIA INK, KOH PREPS)" 3068721001_1 CDM 306 RC 87210 HCPCS outpatient 84 63 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 74.76 89 999999999 65.52 79.8 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; WET MOUNT FOR INFECTIOUS AGENTS (EG, SALINE, INDIA INK, KOH PREPS)" 3068721001_1 CDM 306 RC 87210 HCPCS outpatient 84 63 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 75.6 90 999999999 65.52 79.8 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; WET MOUNT FOR INFECTIOUS AGENTS (EG, SALINE, INDIA INK, KOH PREPS)" 3068721001_1 CDM 306 RC 87210 HCPCS outpatient 84 63 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 79.8 95 999999999 65.52 79.8 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; WET MOUNT FOR INFECTIOUS AGENTS (EG, SALINE, INDIA INK, KOH PREPS)" 3068721001_1 CDM 306 RC 87210 HCPCS outpatient 84 63 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 79.8 95 999999999 65.52 79.8 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; WET MOUNT FOR INFECTIOUS AGENTS (EG, SALINE, INDIA INK, KOH PREPS)" 3068721001_1 CDM 306 RC 87210 HCPCS outpatient 84 63 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 74.76 89 999999999 65.52 79.8 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; WET MOUNT FOR INFECTIOUS AGENTS (EG, SALINE, INDIA INK, KOH PREPS)" 3068721001_1 CDM 306 RC 87210 HCPCS outpatient 84 63 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 73.92 88 999999999 65.52 79.8 percent of total billed charges "SMEAR, PRIMARY SOURCE WITH INTERPRETATION; WET MOUNT FOR INFECTIOUS AGENTS (EG, SALINE, INDIA INK, KOH PREPS)" 3068721001_1 CDM 306 RC 87210 HCPCS outpatient 84 63 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 74.76 89 999999999 65.52 79.8 percent of total billed charges "TISSUE EXAMINATION BY KOH SLIDE OF SAMPLES FROM SKIN, HAIR, OR NAILS FOR FUNGI OR ECTOPARASITE OVA OR MITES (EG, SCABIES)" 3068722001_1 CDM 306 RC 87220 HCPCS outpatient 57 42.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 51.3 90 999999999 44.46 54.15 percent of total billed charges "TISSUE EXAMINATION BY KOH SLIDE OF SAMPLES FROM SKIN, HAIR, OR NAILS FOR FUNGI OR ECTOPARASITE OVA OR MITES (EG, SCABIES)" 3068722001_1 CDM 306 RC 87220 HCPCS outpatient 57 42.75 AETNA MCR ADV AETNA MCR ADV 44.46 78 999999999 44.46 54.15 percent of total billed charges "TISSUE EXAMINATION BY KOH SLIDE OF SAMPLES FROM SKIN, HAIR, OR NAILS FOR FUNGI OR ECTOPARASITE OVA OR MITES (EG, SCABIES)" 3068722001_1 CDM 306 RC 87220 HCPCS outpatient 57 42.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 49.91 87.57 999999999 44.46 54.15 percent of total billed charges "TISSUE EXAMINATION BY KOH SLIDE OF SAMPLES FROM SKIN, HAIR, OR NAILS FOR FUNGI OR ECTOPARASITE OVA OR MITES (EG, SCABIES)" 3068722001_1 CDM 306 RC 87220 HCPCS outpatient 57 42.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 48.49 85.07 999999999 44.46 54.15 percent of total billed charges "TISSUE EXAMINATION BY KOH SLIDE OF SAMPLES FROM SKIN, HAIR, OR NAILS FOR FUNGI OR ECTOPARASITE OVA OR MITES (EG, SCABIES)" 3068722001_1 CDM 306 RC 87220 HCPCS outpatient 57 42.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 48.49 85.07 999999999 44.46 54.15 percent of total billed charges "TISSUE EXAMINATION BY KOH SLIDE OF SAMPLES FROM SKIN, HAIR, OR NAILS FOR FUNGI OR ECTOPARASITE OVA OR MITES (EG, SCABIES)" 3068722001_1 CDM 306 RC 87220 HCPCS outpatient 57 42.75 MOLINA MCAID MOLINA MCAID 47.54 83.4 999999999 44.46 54.15 percent of total billed charges "TISSUE EXAMINATION BY KOH SLIDE OF SAMPLES FROM SKIN, HAIR, OR NAILS FOR FUNGI OR ECTOPARASITE OVA OR MITES (EG, SCABIES)" 3068722001_1 CDM 306 RC 87220 HCPCS outpatient 57 42.75 MOLINA MCR ADV MOLINA MCR ADV 50.73 89 999999999 44.46 54.15 percent of total billed charges "TISSUE EXAMINATION BY KOH SLIDE OF SAMPLES FROM SKIN, HAIR, OR NAILS FOR FUNGI OR ECTOPARASITE OVA OR MITES (EG, SCABIES)" 3068722001_1 CDM 306 RC 87220 HCPCS outpatient 57 42.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50.73 89 999999999 44.46 54.15 percent of total billed charges "TISSUE EXAMINATION BY KOH SLIDE OF SAMPLES FROM SKIN, HAIR, OR NAILS FOR FUNGI OR ECTOPARASITE OVA OR MITES (EG, SCABIES)" 3068722001_1 CDM 306 RC 87220 HCPCS outpatient 57 42.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50.73 89 999999999 44.46 54.15 percent of total billed charges "TISSUE EXAMINATION BY KOH SLIDE OF SAMPLES FROM SKIN, HAIR, OR NAILS FOR FUNGI OR ECTOPARASITE OVA OR MITES (EG, SCABIES)" 3068722001_1 CDM 306 RC 87220 HCPCS outpatient 57 42.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 51.3 90 999999999 44.46 54.15 percent of total billed charges "TISSUE EXAMINATION BY KOH SLIDE OF SAMPLES FROM SKIN, HAIR, OR NAILS FOR FUNGI OR ECTOPARASITE OVA OR MITES (EG, SCABIES)" 3068722001_1 CDM 306 RC 87220 HCPCS outpatient 57 42.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 54.15 95 999999999 44.46 54.15 percent of total billed charges "TISSUE EXAMINATION BY KOH SLIDE OF SAMPLES FROM SKIN, HAIR, OR NAILS FOR FUNGI OR ECTOPARASITE OVA OR MITES (EG, SCABIES)" 3068722001_1 CDM 306 RC 87220 HCPCS outpatient 57 42.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 54.15 95 999999999 44.46 54.15 percent of total billed charges "TISSUE EXAMINATION BY KOH SLIDE OF SAMPLES FROM SKIN, HAIR, OR NAILS FOR FUNGI OR ECTOPARASITE OVA OR MITES (EG, SCABIES)" 3068722001_1 CDM 306 RC 87220 HCPCS outpatient 57 42.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50.73 89 999999999 44.46 54.15 percent of total billed charges "TISSUE EXAMINATION BY KOH SLIDE OF SAMPLES FROM SKIN, HAIR, OR NAILS FOR FUNGI OR ECTOPARASITE OVA OR MITES (EG, SCABIES)" 3068722001_1 CDM 306 RC 87220 HCPCS outpatient 57 42.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50.16 88 999999999 44.46 54.15 percent of total billed charges "TISSUE EXAMINATION BY KOH SLIDE OF SAMPLES FROM SKIN, HAIR, OR NAILS FOR FUNGI OR ECTOPARASITE OVA OR MITES (EG, SCABIES)" 3068722001_1 CDM 306 RC 87220 HCPCS outpatient 57 42.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50.73 89 999999999 44.46 54.15 percent of total billed charges "TOXIN OR ANTITOXIN ASSAY, TISSUE CULTURE (EG, CLOSTRIDIUM DIFFICILE TOXIN)" 3068723001_1 CDM 306 RC 87230 HCPCS outpatient 130 97.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 117 90 999999999 101.4 123.5 percent of total billed charges "TOXIN OR ANTITOXIN ASSAY, TISSUE CULTURE (EG, CLOSTRIDIUM DIFFICILE TOXIN)" 3068723001_1 CDM 306 RC 87230 HCPCS outpatient 130 97.5 AETNA MCR ADV AETNA MCR ADV 101.4 78 999999999 101.4 123.5 percent of total billed charges "TOXIN OR ANTITOXIN ASSAY, TISSUE CULTURE (EG, CLOSTRIDIUM DIFFICILE TOXIN)" 3068723001_1 CDM 306 RC 87230 HCPCS outpatient 130 97.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 113.84 87.57 999999999 101.4 123.5 percent of total billed charges "TOXIN OR ANTITOXIN ASSAY, TISSUE CULTURE (EG, CLOSTRIDIUM DIFFICILE TOXIN)" 3068723001_1 CDM 306 RC 87230 HCPCS outpatient 130 97.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 110.59 85.07 999999999 101.4 123.5 percent of total billed charges "TOXIN OR ANTITOXIN ASSAY, TISSUE CULTURE (EG, CLOSTRIDIUM DIFFICILE TOXIN)" 3068723001_1 CDM 306 RC 87230 HCPCS outpatient 130 97.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 110.59 85.07 999999999 101.4 123.5 percent of total billed charges "TOXIN OR ANTITOXIN ASSAY, TISSUE CULTURE (EG, CLOSTRIDIUM DIFFICILE TOXIN)" 3068723001_1 CDM 306 RC 87230 HCPCS outpatient 130 97.5 MOLINA MCAID MOLINA MCAID 108.42 83.4 999999999 101.4 123.5 percent of total billed charges "TOXIN OR ANTITOXIN ASSAY, TISSUE CULTURE (EG, CLOSTRIDIUM DIFFICILE TOXIN)" 3068723001_1 CDM 306 RC 87230 HCPCS outpatient 130 97.5 MOLINA MCR ADV MOLINA MCR ADV 115.7 89 999999999 101.4 123.5 percent of total billed charges "TOXIN OR ANTITOXIN ASSAY, TISSUE CULTURE (EG, CLOSTRIDIUM DIFFICILE TOXIN)" 3068723001_1 CDM 306 RC 87230 HCPCS outpatient 130 97.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 115.7 89 999999999 101.4 123.5 percent of total billed charges "TOXIN OR ANTITOXIN ASSAY, TISSUE CULTURE (EG, CLOSTRIDIUM DIFFICILE TOXIN)" 3068723001_1 CDM 306 RC 87230 HCPCS outpatient 130 97.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 115.7 89 999999999 101.4 123.5 percent of total billed charges "TOXIN OR ANTITOXIN ASSAY, TISSUE CULTURE (EG, CLOSTRIDIUM DIFFICILE TOXIN)" 3068723001_1 CDM 306 RC 87230 HCPCS outpatient 130 97.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 117 90 999999999 101.4 123.5 percent of total billed charges "TOXIN OR ANTITOXIN ASSAY, TISSUE CULTURE (EG, CLOSTRIDIUM DIFFICILE TOXIN)" 3068723001_1 CDM 306 RC 87230 HCPCS outpatient 130 97.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 123.5 95 999999999 101.4 123.5 percent of total billed charges "TOXIN OR ANTITOXIN ASSAY, TISSUE CULTURE (EG, CLOSTRIDIUM DIFFICILE TOXIN)" 3068723001_1 CDM 306 RC 87230 HCPCS outpatient 130 97.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 123.5 95 999999999 101.4 123.5 percent of total billed charges "TOXIN OR ANTITOXIN ASSAY, TISSUE CULTURE (EG, CLOSTRIDIUM DIFFICILE TOXIN)" 3068723001_1 CDM 306 RC 87230 HCPCS outpatient 130 97.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 115.7 89 999999999 101.4 123.5 percent of total billed charges "TOXIN OR ANTITOXIN ASSAY, TISSUE CULTURE (EG, CLOSTRIDIUM DIFFICILE TOXIN)" 3068723001_1 CDM 306 RC 87230 HCPCS outpatient 130 97.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 114.4 88 999999999 101.4 123.5 percent of total billed charges "TOXIN OR ANTITOXIN ASSAY, TISSUE CULTURE (EG, CLOSTRIDIUM DIFFICILE TOXIN)" 3068723001_1 CDM 306 RC 87230 HCPCS outpatient 130 97.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 115.7 89 999999999 101.4 123.5 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; CLOSTRIDIUM DIFFICILE TOXIN(S)" 3068732401_1 CDM 306 RC 87324 HCPCS outpatient 118 88.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 106.2 90 999999999 92.04 112.1 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; CLOSTRIDIUM DIFFICILE TOXIN(S)" 3068732401_1 CDM 306 RC 87324 HCPCS outpatient 118 88.5 AETNA MCR ADV AETNA MCR ADV 92.04 78 999999999 92.04 112.1 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; CLOSTRIDIUM DIFFICILE TOXIN(S)" 3068732401_1 CDM 306 RC 87324 HCPCS outpatient 118 88.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 103.33 87.57 999999999 92.04 112.1 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; CLOSTRIDIUM DIFFICILE TOXIN(S)" 3068732401_1 CDM 306 RC 87324 HCPCS outpatient 118 88.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 100.38 85.07 999999999 92.04 112.1 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; CLOSTRIDIUM DIFFICILE TOXIN(S)" 3068732401_1 CDM 306 RC 87324 HCPCS outpatient 118 88.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 100.38 85.07 999999999 92.04 112.1 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; CLOSTRIDIUM DIFFICILE TOXIN(S)" 3068732401_1 CDM 306 RC 87324 HCPCS outpatient 118 88.5 MOLINA MCAID MOLINA MCAID 98.41 83.4 999999999 92.04 112.1 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; CLOSTRIDIUM DIFFICILE TOXIN(S)" 3068732401_1 CDM 306 RC 87324 HCPCS outpatient 118 88.5 MOLINA MCR ADV MOLINA MCR ADV 105.02 89 999999999 92.04 112.1 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; CLOSTRIDIUM DIFFICILE TOXIN(S)" 3068732401_1 CDM 306 RC 87324 HCPCS outpatient 118 88.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 105.02 89 999999999 92.04 112.1 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; CLOSTRIDIUM DIFFICILE TOXIN(S)" 3068732401_1 CDM 306 RC 87324 HCPCS outpatient 118 88.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 105.02 89 999999999 92.04 112.1 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; CLOSTRIDIUM DIFFICILE TOXIN(S)" 3068732401_1 CDM 306 RC 87324 HCPCS outpatient 118 88.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 106.2 90 999999999 92.04 112.1 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; CLOSTRIDIUM DIFFICILE TOXIN(S)" 3068732401_1 CDM 306 RC 87324 HCPCS outpatient 118 88.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 112.1 95 999999999 92.04 112.1 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; CLOSTRIDIUM DIFFICILE TOXIN(S)" 3068732401_1 CDM 306 RC 87324 HCPCS outpatient 118 88.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 112.1 95 999999999 92.04 112.1 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; CLOSTRIDIUM DIFFICILE TOXIN(S)" 3068732401_1 CDM 306 RC 87324 HCPCS outpatient 118 88.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 105.02 89 999999999 92.04 112.1 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; CLOSTRIDIUM DIFFICILE TOXIN(S)" 3068732401_1 CDM 306 RC 87324 HCPCS outpatient 118 88.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 103.84 88 999999999 92.04 112.1 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; CLOSTRIDIUM DIFFICILE TOXIN(S)" 3068732401_1 CDM 306 RC 87324 HCPCS outpatient 118 88.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 105.02 89 999999999 92.04 112.1 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; CRYPTOSPORIDIUM" 3068732801_1 CDM 306 RC 87328 HCPCS outpatient 132 99 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 118.8 90 999999999 102.96 125.4 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; CRYPTOSPORIDIUM" 3068732801_1 CDM 306 RC 87328 HCPCS outpatient 132 99 AETNA MCR ADV AETNA MCR ADV 102.96 78 999999999 102.96 125.4 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; CRYPTOSPORIDIUM" 3068732801_1 CDM 306 RC 87328 HCPCS outpatient 132 99 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 115.59 87.57 999999999 102.96 125.4 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; CRYPTOSPORIDIUM" 3068732801_1 CDM 306 RC 87328 HCPCS outpatient 132 99 COORDINATED CARE MCAID COORDINATED CARE MCAID 112.29 85.07 999999999 102.96 125.4 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; CRYPTOSPORIDIUM" 3068732801_1 CDM 306 RC 87328 HCPCS outpatient 132 99 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 112.29 85.07 999999999 102.96 125.4 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; CRYPTOSPORIDIUM" 3068732801_1 CDM 306 RC 87328 HCPCS outpatient 132 99 MOLINA MCAID MOLINA MCAID 110.09 83.4 999999999 102.96 125.4 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; CRYPTOSPORIDIUM" 3068732801_1 CDM 306 RC 87328 HCPCS outpatient 132 99 MOLINA MCR ADV MOLINA MCR ADV 117.48 89 999999999 102.96 125.4 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; CRYPTOSPORIDIUM" 3068732801_1 CDM 306 RC 87328 HCPCS outpatient 132 99 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 117.48 89 999999999 102.96 125.4 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; CRYPTOSPORIDIUM" 3068732801_1 CDM 306 RC 87328 HCPCS outpatient 132 99 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 117.48 89 999999999 102.96 125.4 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; CRYPTOSPORIDIUM" 3068732801_1 CDM 306 RC 87328 HCPCS outpatient 132 99 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 118.8 90 999999999 102.96 125.4 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; CRYPTOSPORIDIUM" 3068732801_1 CDM 306 RC 87328 HCPCS outpatient 132 99 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 125.4 95 999999999 102.96 125.4 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; CRYPTOSPORIDIUM" 3068732801_1 CDM 306 RC 87328 HCPCS outpatient 132 99 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 125.4 95 999999999 102.96 125.4 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; CRYPTOSPORIDIUM" 3068732801_1 CDM 306 RC 87328 HCPCS outpatient 132 99 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 117.48 89 999999999 102.96 125.4 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; CRYPTOSPORIDIUM" 3068732801_1 CDM 306 RC 87328 HCPCS outpatient 132 99 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 116.16 88 999999999 102.96 125.4 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; CRYPTOSPORIDIUM" 3068732801_1 CDM 306 RC 87328 HCPCS outpatient 132 99 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 117.48 89 999999999 102.96 125.4 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; GIARDIA" 3068732901_1 CDM 306 RC 87329 HCPCS outpatient 163 122.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 146.7 90 999999999 127.14 154.85 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; GIARDIA" 3068732901_1 CDM 306 RC 87329 HCPCS outpatient 163 122.25 AETNA MCR ADV AETNA MCR ADV 127.14 78 999999999 127.14 154.85 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; GIARDIA" 3068732901_1 CDM 306 RC 87329 HCPCS outpatient 163 122.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 142.74 87.57 999999999 127.14 154.85 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; GIARDIA" 3068732901_1 CDM 306 RC 87329 HCPCS outpatient 163 122.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 138.66 85.07 999999999 127.14 154.85 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; GIARDIA" 3068732901_1 CDM 306 RC 87329 HCPCS outpatient 163 122.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 138.66 85.07 999999999 127.14 154.85 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; GIARDIA" 3068732901_1 CDM 306 RC 87329 HCPCS outpatient 163 122.25 MOLINA MCAID MOLINA MCAID 135.94 83.4 999999999 127.14 154.85 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; GIARDIA" 3068732901_1 CDM 306 RC 87329 HCPCS outpatient 163 122.25 MOLINA MCR ADV MOLINA MCR ADV 145.07 89 999999999 127.14 154.85 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; GIARDIA" 3068732901_1 CDM 306 RC 87329 HCPCS outpatient 163 122.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 145.07 89 999999999 127.14 154.85 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; GIARDIA" 3068732901_1 CDM 306 RC 87329 HCPCS outpatient 163 122.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 145.07 89 999999999 127.14 154.85 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; GIARDIA" 3068732901_1 CDM 306 RC 87329 HCPCS outpatient 163 122.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 146.7 90 999999999 127.14 154.85 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; GIARDIA" 3068732901_1 CDM 306 RC 87329 HCPCS outpatient 163 122.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 154.85 95 999999999 127.14 154.85 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; GIARDIA" 3068732901_1 CDM 306 RC 87329 HCPCS outpatient 163 122.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 154.85 95 999999999 127.14 154.85 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; GIARDIA" 3068732901_1 CDM 306 RC 87329 HCPCS outpatient 163 122.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 145.07 89 999999999 127.14 154.85 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; GIARDIA" 3068732901_1 CDM 306 RC 87329 HCPCS outpatient 163 122.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 143.44 88 999999999 127.14 154.85 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; GIARDIA" 3068732901_1 CDM 306 RC 87329 HCPCS outpatient 163 122.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 145.07 89 999999999 127.14 154.85 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HELICOBACTER PYLORI, STOOL" 3068733801_1 CDM 306 RC 87338 HCPCS outpatient 179 134.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 161.1 90 999999999 139.62 170.05 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HELICOBACTER PYLORI, STOOL" 3068733801_1 CDM 306 RC 87338 HCPCS outpatient 179 134.25 AETNA MCR ADV AETNA MCR ADV 139.62 78 999999999 139.62 170.05 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HELICOBACTER PYLORI, STOOL" 3068733801_1 CDM 306 RC 87338 HCPCS outpatient 179 134.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 156.75 87.57 999999999 139.62 170.05 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HELICOBACTER PYLORI, STOOL" 3068733801_1 CDM 306 RC 87338 HCPCS outpatient 179 134.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 152.28 85.07 999999999 139.62 170.05 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HELICOBACTER PYLORI, STOOL" 3068733801_1 CDM 306 RC 87338 HCPCS outpatient 179 134.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 152.28 85.07 999999999 139.62 170.05 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HELICOBACTER PYLORI, STOOL" 3068733801_1 CDM 306 RC 87338 HCPCS outpatient 179 134.25 MOLINA MCAID MOLINA MCAID 149.29 83.4 999999999 139.62 170.05 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HELICOBACTER PYLORI, STOOL" 3068733801_1 CDM 306 RC 87338 HCPCS outpatient 179 134.25 MOLINA MCR ADV MOLINA MCR ADV 159.31 89 999999999 139.62 170.05 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HELICOBACTER PYLORI, STOOL" 3068733801_1 CDM 306 RC 87338 HCPCS outpatient 179 134.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 159.31 89 999999999 139.62 170.05 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HELICOBACTER PYLORI, STOOL" 3068733801_1 CDM 306 RC 87338 HCPCS outpatient 179 134.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 159.31 89 999999999 139.62 170.05 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HELICOBACTER PYLORI, STOOL" 3068733801_1 CDM 306 RC 87338 HCPCS outpatient 179 134.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 161.1 90 999999999 139.62 170.05 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HELICOBACTER PYLORI, STOOL" 3068733801_1 CDM 306 RC 87338 HCPCS outpatient 179 134.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 170.05 95 999999999 139.62 170.05 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HELICOBACTER PYLORI, STOOL" 3068733801_1 CDM 306 RC 87338 HCPCS outpatient 179 134.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 170.05 95 999999999 139.62 170.05 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HELICOBACTER PYLORI, STOOL" 3068733801_1 CDM 306 RC 87338 HCPCS outpatient 179 134.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 159.31 89 999999999 139.62 170.05 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HELICOBACTER PYLORI, STOOL" 3068733801_1 CDM 306 RC 87338 HCPCS outpatient 179 134.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 157.52 88 999999999 139.62 170.05 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HELICOBACTER PYLORI, STOOL" 3068733801_1 CDM 306 RC 87338 HCPCS outpatient 179 134.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 159.31 89 999999999 139.62 170.05 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HEPATITIS B SURFACE ANTIGEN (HBSAG)" 3068734001_1 CDM 306 RC 87340 HCPCS outpatient 90 67.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 81 90 999999999 70.2 85.5 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HEPATITIS B SURFACE ANTIGEN (HBSAG)" 3068734001_1 CDM 306 RC 87340 HCPCS outpatient 90 67.5 AETNA MCR ADV AETNA MCR ADV 70.2 78 999999999 70.2 85.5 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HEPATITIS B SURFACE ANTIGEN (HBSAG)" 3068734001_1 CDM 306 RC 87340 HCPCS outpatient 90 67.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 78.81 87.57 999999999 70.2 85.5 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HEPATITIS B SURFACE ANTIGEN (HBSAG)" 3068734001_1 CDM 306 RC 87340 HCPCS outpatient 90 67.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 76.56 85.07 999999999 70.2 85.5 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HEPATITIS B SURFACE ANTIGEN (HBSAG)" 3068734001_1 CDM 306 RC 87340 HCPCS outpatient 90 67.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 76.56 85.07 999999999 70.2 85.5 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HEPATITIS B SURFACE ANTIGEN (HBSAG)" 3068734001_1 CDM 306 RC 87340 HCPCS outpatient 90 67.5 MOLINA MCAID MOLINA MCAID 75.06 83.4 999999999 70.2 85.5 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HEPATITIS B SURFACE ANTIGEN (HBSAG)" 3068734001_1 CDM 306 RC 87340 HCPCS outpatient 90 67.5 MOLINA MCR ADV MOLINA MCR ADV 80.1 89 999999999 70.2 85.5 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HEPATITIS B SURFACE ANTIGEN (HBSAG)" 3068734001_1 CDM 306 RC 87340 HCPCS outpatient 90 67.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 80.1 89 999999999 70.2 85.5 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HEPATITIS B SURFACE ANTIGEN (HBSAG)" 3068734001_1 CDM 306 RC 87340 HCPCS outpatient 90 67.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 80.1 89 999999999 70.2 85.5 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HEPATITIS B SURFACE ANTIGEN (HBSAG)" 3068734001_1 CDM 306 RC 87340 HCPCS outpatient 90 67.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 81 90 999999999 70.2 85.5 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HEPATITIS B SURFACE ANTIGEN (HBSAG)" 3068734001_1 CDM 306 RC 87340 HCPCS outpatient 90 67.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 85.5 95 999999999 70.2 85.5 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HEPATITIS B SURFACE ANTIGEN (HBSAG)" 3068734001_1 CDM 306 RC 87340 HCPCS outpatient 90 67.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 85.5 95 999999999 70.2 85.5 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HEPATITIS B SURFACE ANTIGEN (HBSAG)" 3068734001_1 CDM 306 RC 87340 HCPCS outpatient 90 67.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 80.1 89 999999999 70.2 85.5 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HEPATITIS B SURFACE ANTIGEN (HBSAG)" 3068734001_1 CDM 306 RC 87340 HCPCS outpatient 90 67.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 79.2 88 999999999 70.2 85.5 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HEPATITIS B SURFACE ANTIGEN (HBSAG)" 3068734001_1 CDM 306 RC 87340 HCPCS outpatient 90 67.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 80.1 89 999999999 70.2 85.5 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HIV-1 ANTIGEN(S), WITH HIV-1 AND HIV-2 ANTIBODIES, SINGLE RESULT" 3068738901_1 CDM 306 RC 87389 HCPCS outpatient 128 96 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 115.2 90 999999999 99.84 121.6 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HIV-1 ANTIGEN(S), WITH HIV-1 AND HIV-2 ANTIBODIES, SINGLE RESULT" 3068738901_1 CDM 306 RC 87389 HCPCS outpatient 128 96 AETNA MCR ADV AETNA MCR ADV 99.84 78 999999999 99.84 121.6 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HIV-1 ANTIGEN(S), WITH HIV-1 AND HIV-2 ANTIBODIES, SINGLE RESULT" 3068738901_1 CDM 306 RC 87389 HCPCS outpatient 128 96 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 112.09 87.57 999999999 99.84 121.6 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HIV-1 ANTIGEN(S), WITH HIV-1 AND HIV-2 ANTIBODIES, SINGLE RESULT" 3068738901_1 CDM 306 RC 87389 HCPCS outpatient 128 96 COORDINATED CARE MCAID COORDINATED CARE MCAID 108.89 85.07 999999999 99.84 121.6 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HIV-1 ANTIGEN(S), WITH HIV-1 AND HIV-2 ANTIBODIES, SINGLE RESULT" 3068738901_1 CDM 306 RC 87389 HCPCS outpatient 128 96 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 108.89 85.07 999999999 99.84 121.6 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HIV-1 ANTIGEN(S), WITH HIV-1 AND HIV-2 ANTIBODIES, SINGLE RESULT" 3068738901_1 CDM 306 RC 87389 HCPCS outpatient 128 96 MOLINA MCAID MOLINA MCAID 106.75 83.4 999999999 99.84 121.6 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HIV-1 ANTIGEN(S), WITH HIV-1 AND HIV-2 ANTIBODIES, SINGLE RESULT" 3068738901_1 CDM 306 RC 87389 HCPCS outpatient 128 96 MOLINA MCR ADV MOLINA MCR ADV 113.92 89 999999999 99.84 121.6 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HIV-1 ANTIGEN(S), WITH HIV-1 AND HIV-2 ANTIBODIES, SINGLE RESULT" 3068738901_1 CDM 306 RC 87389 HCPCS outpatient 128 96 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 113.92 89 999999999 99.84 121.6 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HIV-1 ANTIGEN(S), WITH HIV-1 AND HIV-2 ANTIBODIES, SINGLE RESULT" 3068738901_1 CDM 306 RC 87389 HCPCS outpatient 128 96 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 113.92 89 999999999 99.84 121.6 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HIV-1 ANTIGEN(S), WITH HIV-1 AND HIV-2 ANTIBODIES, SINGLE RESULT" 3068738901_1 CDM 306 RC 87389 HCPCS outpatient 128 96 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 115.2 90 999999999 99.84 121.6 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HIV-1 ANTIGEN(S), WITH HIV-1 AND HIV-2 ANTIBODIES, SINGLE RESULT" 3068738901_1 CDM 306 RC 87389 HCPCS outpatient 128 96 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 121.6 95 999999999 99.84 121.6 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HIV-1 ANTIGEN(S), WITH HIV-1 AND HIV-2 ANTIBODIES, SINGLE RESULT" 3068738901_1 CDM 306 RC 87389 HCPCS outpatient 128 96 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 121.6 95 999999999 99.84 121.6 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HIV-1 ANTIGEN(S), WITH HIV-1 AND HIV-2 ANTIBODIES, SINGLE RESULT" 3068738901_1 CDM 306 RC 87389 HCPCS outpatient 128 96 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 113.92 89 999999999 99.84 121.6 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HIV-1 ANTIGEN(S), WITH HIV-1 AND HIV-2 ANTIBODIES, SINGLE RESULT" 3068738901_1 CDM 306 RC 87389 HCPCS outpatient 128 96 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 112.64 88 999999999 99.84 121.6 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; HIV-1 ANTIGEN(S), WITH HIV-1 AND HIV-2 ANTIBODIES, SINGLE RESULT" 3068738901_1 CDM 306 RC 87389 HCPCS outpatient 128 96 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 113.92 89 999999999 99.84 121.6 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; INFLUENZA, A OR B, EACH" 3068740001_1 CDM 306 RC 87400 HCPCS outpatient 125 93.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 112.5 90 999999999 97.5 118.75 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; INFLUENZA, A OR B, EACH" 3068740001_1 CDM 306 RC 87400 HCPCS outpatient 125 93.75 AETNA MCR ADV AETNA MCR ADV 97.5 78 999999999 97.5 118.75 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; INFLUENZA, A OR B, EACH" 3068740001_1 CDM 306 RC 87400 HCPCS outpatient 125 93.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 109.46 87.57 999999999 97.5 118.75 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; INFLUENZA, A OR B, EACH" 3068740001_1 CDM 306 RC 87400 HCPCS outpatient 125 93.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 106.34 85.07 999999999 97.5 118.75 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; INFLUENZA, A OR B, EACH" 3068740001_1 CDM 306 RC 87400 HCPCS outpatient 125 93.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 106.34 85.07 999999999 97.5 118.75 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; INFLUENZA, A OR B, EACH" 3068740001_1 CDM 306 RC 87400 HCPCS outpatient 125 93.75 MOLINA MCAID MOLINA MCAID 104.25 83.4 999999999 97.5 118.75 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; INFLUENZA, A OR B, EACH" 3068740001_1 CDM 306 RC 87400 HCPCS outpatient 125 93.75 MOLINA MCR ADV MOLINA MCR ADV 111.25 89 999999999 97.5 118.75 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; INFLUENZA, A OR B, EACH" 3068740001_1 CDM 306 RC 87400 HCPCS outpatient 125 93.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 111.25 89 999999999 97.5 118.75 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; INFLUENZA, A OR B, EACH" 3068740001_1 CDM 306 RC 87400 HCPCS outpatient 125 93.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 111.25 89 999999999 97.5 118.75 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; INFLUENZA, A OR B, EACH" 3068740001_1 CDM 306 RC 87400 HCPCS outpatient 125 93.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 112.5 90 999999999 97.5 118.75 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; INFLUENZA, A OR B, EACH" 3068740001_1 CDM 306 RC 87400 HCPCS outpatient 125 93.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 118.75 95 999999999 97.5 118.75 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; INFLUENZA, A OR B, EACH" 3068740001_1 CDM 306 RC 87400 HCPCS outpatient 125 93.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 118.75 95 999999999 97.5 118.75 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; INFLUENZA, A OR B, EACH" 3068740001_1 CDM 306 RC 87400 HCPCS outpatient 125 93.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 111.25 89 999999999 97.5 118.75 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; INFLUENZA, A OR B, EACH" 3068740001_1 CDM 306 RC 87400 HCPCS outpatient 125 93.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 110 88 999999999 97.5 118.75 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; INFLUENZA, A OR B, EACH" 3068740001_1 CDM 306 RC 87400 HCPCS outpatient 125 93.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 111.25 89 999999999 97.5 118.75 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; RESPIRATORY SYNCYTIAL VIRUS" 3068742001_1 CDM 306 RC 87420 HCPCS outpatient 67 50.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 60.3 90 999999999 52.26 63.65 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; RESPIRATORY SYNCYTIAL VIRUS" 3068742001_1 CDM 306 RC 87420 HCPCS outpatient 67 50.25 AETNA MCR ADV AETNA MCR ADV 52.26 78 999999999 52.26 63.65 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; RESPIRATORY SYNCYTIAL VIRUS" 3068742001_1 CDM 306 RC 87420 HCPCS outpatient 67 50.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 58.67 87.57 999999999 52.26 63.65 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; RESPIRATORY SYNCYTIAL VIRUS" 3068742001_1 CDM 306 RC 87420 HCPCS outpatient 67 50.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 57 85.07 999999999 52.26 63.65 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; RESPIRATORY SYNCYTIAL VIRUS" 3068742001_1 CDM 306 RC 87420 HCPCS outpatient 67 50.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 57 85.07 999999999 52.26 63.65 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; RESPIRATORY SYNCYTIAL VIRUS" 3068742001_1 CDM 306 RC 87420 HCPCS outpatient 67 50.25 MOLINA MCAID MOLINA MCAID 55.88 83.4 999999999 52.26 63.65 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; RESPIRATORY SYNCYTIAL VIRUS" 3068742001_1 CDM 306 RC 87420 HCPCS outpatient 67 50.25 MOLINA MCR ADV MOLINA MCR ADV 59.63 89 999999999 52.26 63.65 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; RESPIRATORY SYNCYTIAL VIRUS" 3068742001_1 CDM 306 RC 87420 HCPCS outpatient 67 50.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 59.63 89 999999999 52.26 63.65 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; RESPIRATORY SYNCYTIAL VIRUS" 3068742001_1 CDM 306 RC 87420 HCPCS outpatient 67 50.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 59.63 89 999999999 52.26 63.65 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; RESPIRATORY SYNCYTIAL VIRUS" 3068742001_1 CDM 306 RC 87420 HCPCS outpatient 67 50.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 60.3 90 999999999 52.26 63.65 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; RESPIRATORY SYNCYTIAL VIRUS" 3068742001_1 CDM 306 RC 87420 HCPCS outpatient 67 50.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 63.65 95 999999999 52.26 63.65 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; RESPIRATORY SYNCYTIAL VIRUS" 3068742001_1 CDM 306 RC 87420 HCPCS outpatient 67 50.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 63.65 95 999999999 52.26 63.65 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; RESPIRATORY SYNCYTIAL VIRUS" 3068742001_1 CDM 306 RC 87420 HCPCS outpatient 67 50.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 59.63 89 999999999 52.26 63.65 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; RESPIRATORY SYNCYTIAL VIRUS" 3068742001_1 CDM 306 RC 87420 HCPCS outpatient 67 50.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 58.96 88 999999999 52.26 63.65 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; RESPIRATORY SYNCYTIAL VIRUS" 3068742001_1 CDM 306 RC 87420 HCPCS outpatient 67 50.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 59.63 89 999999999 52.26 63.65 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; ROTAVIRUS" 3068742501_1 CDM 306 RC 87425 HCPCS outpatient 127 95.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 114.3 90 999999999 99.06 120.65 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; ROTAVIRUS" 3068742501_1 CDM 306 RC 87425 HCPCS outpatient 127 95.25 AETNA MCR ADV AETNA MCR ADV 99.06 78 999999999 99.06 120.65 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; ROTAVIRUS" 3068742501_1 CDM 306 RC 87425 HCPCS outpatient 127 95.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 111.21 87.57 999999999 99.06 120.65 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; ROTAVIRUS" 3068742501_1 CDM 306 RC 87425 HCPCS outpatient 127 95.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 108.04 85.07 999999999 99.06 120.65 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; ROTAVIRUS" 3068742501_1 CDM 306 RC 87425 HCPCS outpatient 127 95.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 108.04 85.07 999999999 99.06 120.65 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; ROTAVIRUS" 3068742501_1 CDM 306 RC 87425 HCPCS outpatient 127 95.25 MOLINA MCAID MOLINA MCAID 105.92 83.4 999999999 99.06 120.65 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; ROTAVIRUS" 3068742501_1 CDM 306 RC 87425 HCPCS outpatient 127 95.25 MOLINA MCR ADV MOLINA MCR ADV 113.03 89 999999999 99.06 120.65 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; ROTAVIRUS" 3068742501_1 CDM 306 RC 87425 HCPCS outpatient 127 95.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 113.03 89 999999999 99.06 120.65 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; ROTAVIRUS" 3068742501_1 CDM 306 RC 87425 HCPCS outpatient 127 95.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 113.03 89 999999999 99.06 120.65 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; ROTAVIRUS" 3068742501_1 CDM 306 RC 87425 HCPCS outpatient 127 95.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 114.3 90 999999999 99.06 120.65 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; ROTAVIRUS" 3068742501_1 CDM 306 RC 87425 HCPCS outpatient 127 95.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 120.65 95 999999999 99.06 120.65 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; ROTAVIRUS" 3068742501_1 CDM 306 RC 87425 HCPCS outpatient 127 95.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 120.65 95 999999999 99.06 120.65 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; ROTAVIRUS" 3068742501_1 CDM 306 RC 87425 HCPCS outpatient 127 95.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 113.03 89 999999999 99.06 120.65 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; ROTAVIRUS" 3068742501_1 CDM 306 RC 87425 HCPCS outpatient 127 95.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 111.76 88 999999999 99.06 120.65 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; ROTAVIRUS" 3068742501_1 CDM 306 RC 87425 HCPCS outpatient 127 95.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 113.03 89 999999999 99.06 120.65 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; STREPTOCOCCUS, GROUP A" 3068743001_1 CDM 306 RC 87430 HCPCS outpatient 96 72 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 86.4 90 999999999 74.88 91.2 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; STREPTOCOCCUS, GROUP A" 3068743001_1 CDM 306 RC 87430 HCPCS outpatient 96 72 AETNA MCR ADV AETNA MCR ADV 74.88 78 999999999 74.88 91.2 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; STREPTOCOCCUS, GROUP A" 3068743001_1 CDM 306 RC 87430 HCPCS outpatient 96 72 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 84.07 87.57 999999999 74.88 91.2 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; STREPTOCOCCUS, GROUP A" 3068743001_1 CDM 306 RC 87430 HCPCS outpatient 96 72 COORDINATED CARE MCAID COORDINATED CARE MCAID 81.67 85.07 999999999 74.88 91.2 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; STREPTOCOCCUS, GROUP A" 3068743001_1 CDM 306 RC 87430 HCPCS outpatient 96 72 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 81.67 85.07 999999999 74.88 91.2 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; STREPTOCOCCUS, GROUP A" 3068743001_1 CDM 306 RC 87430 HCPCS outpatient 96 72 MOLINA MCAID MOLINA MCAID 80.06 83.4 999999999 74.88 91.2 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; STREPTOCOCCUS, GROUP A" 3068743001_1 CDM 306 RC 87430 HCPCS outpatient 96 72 MOLINA MCR ADV MOLINA MCR ADV 85.44 89 999999999 74.88 91.2 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; STREPTOCOCCUS, GROUP A" 3068743001_1 CDM 306 RC 87430 HCPCS outpatient 96 72 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 85.44 89 999999999 74.88 91.2 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; STREPTOCOCCUS, GROUP A" 3068743001_1 CDM 306 RC 87430 HCPCS outpatient 96 72 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 85.44 89 999999999 74.88 91.2 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; STREPTOCOCCUS, GROUP A" 3068743001_1 CDM 306 RC 87430 HCPCS outpatient 96 72 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 86.4 90 999999999 74.88 91.2 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; STREPTOCOCCUS, GROUP A" 3068743001_1 CDM 306 RC 87430 HCPCS outpatient 96 72 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 91.2 95 999999999 74.88 91.2 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; STREPTOCOCCUS, GROUP A" 3068743001_1 CDM 306 RC 87430 HCPCS outpatient 96 72 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 91.2 95 999999999 74.88 91.2 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; STREPTOCOCCUS, GROUP A" 3068743001_1 CDM 306 RC 87430 HCPCS outpatient 96 72 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 85.44 89 999999999 74.88 91.2 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; STREPTOCOCCUS, GROUP A" 3068743001_1 CDM 306 RC 87430 HCPCS outpatient 96 72 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 84.48 88 999999999 74.88 91.2 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; STREPTOCOCCUS, GROUP A" 3068743001_1 CDM 306 RC 87430 HCPCS outpatient 96 72 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 85.44 89 999999999 74.88 91.2 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; NOT OTHERWISE SPECIFIED, EACH ORGANISM" 3068744902_1 CDM 306 RC 87449 HCPCS outpatient 164 123 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 147.6 90 999999999 127.92 155.8 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; NOT OTHERWISE SPECIFIED, EACH ORGANISM" 3068744902_1 CDM 306 RC 87449 HCPCS outpatient 164 123 AETNA MCR ADV AETNA MCR ADV 127.92 78 999999999 127.92 155.8 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; NOT OTHERWISE SPECIFIED, EACH ORGANISM" 3068744902_1 CDM 306 RC 87449 HCPCS outpatient 164 123 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 143.61 87.57 999999999 127.92 155.8 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; NOT OTHERWISE SPECIFIED, EACH ORGANISM" 3068744902_1 CDM 306 RC 87449 HCPCS outpatient 164 123 COORDINATED CARE MCAID COORDINATED CARE MCAID 139.51 85.07 999999999 127.92 155.8 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; NOT OTHERWISE SPECIFIED, EACH ORGANISM" 3068744902_1 CDM 306 RC 87449 HCPCS outpatient 164 123 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 139.51 85.07 999999999 127.92 155.8 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; NOT OTHERWISE SPECIFIED, EACH ORGANISM" 3068744902_1 CDM 306 RC 87449 HCPCS outpatient 164 123 MOLINA MCAID MOLINA MCAID 136.78 83.4 999999999 127.92 155.8 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; NOT OTHERWISE SPECIFIED, EACH ORGANISM" 3068744902_1 CDM 306 RC 87449 HCPCS outpatient 164 123 MOLINA MCR ADV MOLINA MCR ADV 145.96 89 999999999 127.92 155.8 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; NOT OTHERWISE SPECIFIED, EACH ORGANISM" 3068744902_1 CDM 306 RC 87449 HCPCS outpatient 164 123 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 145.96 89 999999999 127.92 155.8 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; NOT OTHERWISE SPECIFIED, EACH ORGANISM" 3068744902_1 CDM 306 RC 87449 HCPCS outpatient 164 123 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 145.96 89 999999999 127.92 155.8 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; NOT OTHERWISE SPECIFIED, EACH ORGANISM" 3068744902_1 CDM 306 RC 87449 HCPCS outpatient 164 123 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 147.6 90 999999999 127.92 155.8 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; NOT OTHERWISE SPECIFIED, EACH ORGANISM" 3068744902_1 CDM 306 RC 87449 HCPCS outpatient 164 123 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 155.8 95 999999999 127.92 155.8 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; NOT OTHERWISE SPECIFIED, EACH ORGANISM" 3068744902_1 CDM 306 RC 87449 HCPCS outpatient 164 123 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 155.8 95 999999999 127.92 155.8 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; NOT OTHERWISE SPECIFIED, EACH ORGANISM" 3068744902_1 CDM 306 RC 87449 HCPCS outpatient 164 123 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 145.96 89 999999999 127.92 155.8 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; NOT OTHERWISE SPECIFIED, EACH ORGANISM" 3068744902_1 CDM 306 RC 87449 HCPCS outpatient 164 123 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 144.32 88 999999999 127.92 155.8 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY TECHNIQUE (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], FLUORESCENCE IMMUNOASSAY [FIA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTITATIVE; NOT OTHERWISE SPECIFIED, EACH ORGANISM" 3068744902_1 CDM 306 RC 87449 HCPCS outpatient 164 123 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 145.96 89 999999999 127.92 155.8 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CHLAMYDIA TRACHOMATIS, AMPLIFIED PROBE TECHNIQUE" 3068749102_1 CDM 306 RC 87491 HCPCS outpatient 173 129.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 155.7 90 999999999 134.94 164.35 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CHLAMYDIA TRACHOMATIS, AMPLIFIED PROBE TECHNIQUE" 3068749102_1 CDM 306 RC 87491 HCPCS outpatient 173 129.75 AETNA MCR ADV AETNA MCR ADV 134.94 78 999999999 134.94 164.35 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CHLAMYDIA TRACHOMATIS, AMPLIFIED PROBE TECHNIQUE" 3068749102_1 CDM 306 RC 87491 HCPCS outpatient 173 129.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 151.5 87.57 999999999 134.94 164.35 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CHLAMYDIA TRACHOMATIS, AMPLIFIED PROBE TECHNIQUE" 3068749102_1 CDM 306 RC 87491 HCPCS outpatient 173 129.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 147.17 85.07 999999999 134.94 164.35 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CHLAMYDIA TRACHOMATIS, AMPLIFIED PROBE TECHNIQUE" 3068749102_1 CDM 306 RC 87491 HCPCS outpatient 173 129.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 147.17 85.07 999999999 134.94 164.35 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CHLAMYDIA TRACHOMATIS, AMPLIFIED PROBE TECHNIQUE" 3068749102_1 CDM 306 RC 87491 HCPCS outpatient 173 129.75 MOLINA MCAID MOLINA MCAID 144.28 83.4 999999999 134.94 164.35 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CHLAMYDIA TRACHOMATIS, AMPLIFIED PROBE TECHNIQUE" 3068749102_1 CDM 306 RC 87491 HCPCS outpatient 173 129.75 MOLINA MCR ADV MOLINA MCR ADV 153.97 89 999999999 134.94 164.35 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CHLAMYDIA TRACHOMATIS, AMPLIFIED PROBE TECHNIQUE" 3068749102_1 CDM 306 RC 87491 HCPCS outpatient 173 129.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 153.97 89 999999999 134.94 164.35 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CHLAMYDIA TRACHOMATIS, AMPLIFIED PROBE TECHNIQUE" 3068749102_1 CDM 306 RC 87491 HCPCS outpatient 173 129.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 153.97 89 999999999 134.94 164.35 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CHLAMYDIA TRACHOMATIS, AMPLIFIED PROBE TECHNIQUE" 3068749102_1 CDM 306 RC 87491 HCPCS outpatient 173 129.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 155.7 90 999999999 134.94 164.35 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CHLAMYDIA TRACHOMATIS, AMPLIFIED PROBE TECHNIQUE" 3068749102_1 CDM 306 RC 87491 HCPCS outpatient 173 129.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 164.35 95 999999999 134.94 164.35 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CHLAMYDIA TRACHOMATIS, AMPLIFIED PROBE TECHNIQUE" 3068749102_1 CDM 306 RC 87491 HCPCS outpatient 173 129.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 164.35 95 999999999 134.94 164.35 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CHLAMYDIA TRACHOMATIS, AMPLIFIED PROBE TECHNIQUE" 3068749102_1 CDM 306 RC 87491 HCPCS outpatient 173 129.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 153.97 89 999999999 134.94 164.35 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CHLAMYDIA TRACHOMATIS, AMPLIFIED PROBE TECHNIQUE" 3068749102_1 CDM 306 RC 87491 HCPCS outpatient 173 129.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 152.24 88 999999999 134.94 164.35 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CHLAMYDIA TRACHOMATIS, AMPLIFIED PROBE TECHNIQUE" 3068749102_1 CDM 306 RC 87491 HCPCS outpatient 173 129.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 153.97 89 999999999 134.94 164.35 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); INFLUENZA VIRUS, FOR MULTIPLE TYPES OR SUB-TYPES, INCLUDES MULTIPLEX REVERSE TRANSCRIPTION, WHEN PERFORMED, AND MULTIPLEX AMPLIFIED PROBE TECHNIQUE, FIRST 2 TYPES OR SUB-TYPES" 3068750202_1 CDM 306 RC 87502 HCPCS outpatient 182 136.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 163.8 90 999999999 141.96 172.9 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); INFLUENZA VIRUS, FOR MULTIPLE TYPES OR SUB-TYPES, INCLUDES MULTIPLEX REVERSE TRANSCRIPTION, WHEN PERFORMED, AND MULTIPLEX AMPLIFIED PROBE TECHNIQUE, FIRST 2 TYPES OR SUB-TYPES" 3068750202_1 CDM 306 RC 87502 HCPCS outpatient 182 136.5 AETNA MCR ADV AETNA MCR ADV 141.96 78 999999999 141.96 172.9 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); INFLUENZA VIRUS, FOR MULTIPLE TYPES OR SUB-TYPES, INCLUDES MULTIPLEX REVERSE TRANSCRIPTION, WHEN PERFORMED, AND MULTIPLEX AMPLIFIED PROBE TECHNIQUE, FIRST 2 TYPES OR SUB-TYPES" 3068750202_1 CDM 306 RC 87502 HCPCS outpatient 182 136.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 159.38 87.57 999999999 141.96 172.9 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); INFLUENZA VIRUS, FOR MULTIPLE TYPES OR SUB-TYPES, INCLUDES MULTIPLEX REVERSE TRANSCRIPTION, WHEN PERFORMED, AND MULTIPLEX AMPLIFIED PROBE TECHNIQUE, FIRST 2 TYPES OR SUB-TYPES" 3068750202_1 CDM 306 RC 87502 HCPCS outpatient 182 136.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 154.83 85.07 999999999 141.96 172.9 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); INFLUENZA VIRUS, FOR MULTIPLE TYPES OR SUB-TYPES, INCLUDES MULTIPLEX REVERSE TRANSCRIPTION, WHEN PERFORMED, AND MULTIPLEX AMPLIFIED PROBE TECHNIQUE, FIRST 2 TYPES OR SUB-TYPES" 3068750202_1 CDM 306 RC 87502 HCPCS outpatient 182 136.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 154.83 85.07 999999999 141.96 172.9 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); INFLUENZA VIRUS, FOR MULTIPLE TYPES OR SUB-TYPES, INCLUDES MULTIPLEX REVERSE TRANSCRIPTION, WHEN PERFORMED, AND MULTIPLEX AMPLIFIED PROBE TECHNIQUE, FIRST 2 TYPES OR SUB-TYPES" 3068750202_1 CDM 306 RC 87502 HCPCS outpatient 182 136.5 MOLINA MCAID MOLINA MCAID 151.79 83.4 999999999 141.96 172.9 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); INFLUENZA VIRUS, FOR MULTIPLE TYPES OR SUB-TYPES, INCLUDES MULTIPLEX REVERSE TRANSCRIPTION, WHEN PERFORMED, AND MULTIPLEX AMPLIFIED PROBE TECHNIQUE, FIRST 2 TYPES OR SUB-TYPES" 3068750202_1 CDM 306 RC 87502 HCPCS outpatient 182 136.5 MOLINA MCR ADV MOLINA MCR ADV 161.98 89 999999999 141.96 172.9 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); INFLUENZA VIRUS, FOR MULTIPLE TYPES OR SUB-TYPES, INCLUDES MULTIPLEX REVERSE TRANSCRIPTION, WHEN PERFORMED, AND MULTIPLEX AMPLIFIED PROBE TECHNIQUE, FIRST 2 TYPES OR SUB-TYPES" 3068750202_1 CDM 306 RC 87502 HCPCS outpatient 182 136.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 161.98 89 999999999 141.96 172.9 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); INFLUENZA VIRUS, FOR MULTIPLE TYPES OR SUB-TYPES, INCLUDES MULTIPLEX REVERSE TRANSCRIPTION, WHEN PERFORMED, AND MULTIPLEX AMPLIFIED PROBE TECHNIQUE, FIRST 2 TYPES OR SUB-TYPES" 3068750202_1 CDM 306 RC 87502 HCPCS outpatient 182 136.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 161.98 89 999999999 141.96 172.9 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); INFLUENZA VIRUS, FOR MULTIPLE TYPES OR SUB-TYPES, INCLUDES MULTIPLEX REVERSE TRANSCRIPTION, WHEN PERFORMED, AND MULTIPLEX AMPLIFIED PROBE TECHNIQUE, FIRST 2 TYPES OR SUB-TYPES" 3068750202_1 CDM 306 RC 87502 HCPCS outpatient 182 136.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 163.8 90 999999999 141.96 172.9 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); INFLUENZA VIRUS, FOR MULTIPLE TYPES OR SUB-TYPES, INCLUDES MULTIPLEX REVERSE TRANSCRIPTION, WHEN PERFORMED, AND MULTIPLEX AMPLIFIED PROBE TECHNIQUE, FIRST 2 TYPES OR SUB-TYPES" 3068750202_1 CDM 306 RC 87502 HCPCS outpatient 182 136.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 172.9 95 999999999 141.96 172.9 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); INFLUENZA VIRUS, FOR MULTIPLE TYPES OR SUB-TYPES, INCLUDES MULTIPLEX REVERSE TRANSCRIPTION, WHEN PERFORMED, AND MULTIPLEX AMPLIFIED PROBE TECHNIQUE, FIRST 2 TYPES OR SUB-TYPES" 3068750202_1 CDM 306 RC 87502 HCPCS outpatient 182 136.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 172.9 95 999999999 141.96 172.9 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); INFLUENZA VIRUS, FOR MULTIPLE TYPES OR SUB-TYPES, INCLUDES MULTIPLEX REVERSE TRANSCRIPTION, WHEN PERFORMED, AND MULTIPLEX AMPLIFIED PROBE TECHNIQUE, FIRST 2 TYPES OR SUB-TYPES" 3068750202_1 CDM 306 RC 87502 HCPCS outpatient 182 136.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 161.98 89 999999999 141.96 172.9 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); INFLUENZA VIRUS, FOR MULTIPLE TYPES OR SUB-TYPES, INCLUDES MULTIPLEX REVERSE TRANSCRIPTION, WHEN PERFORMED, AND MULTIPLEX AMPLIFIED PROBE TECHNIQUE, FIRST 2 TYPES OR SUB-TYPES" 3068750202_1 CDM 306 RC 87502 HCPCS outpatient 182 136.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 160.16 88 999999999 141.96 172.9 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); INFLUENZA VIRUS, FOR MULTIPLE TYPES OR SUB-TYPES, INCLUDES MULTIPLEX REVERSE TRANSCRIPTION, WHEN PERFORMED, AND MULTIPLEX AMPLIFIED PROBE TECHNIQUE, FIRST 2 TYPES OR SUB-TYPES" 3068750202_1 CDM 306 RC 87502 HCPCS outpatient 182 136.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 161.98 89 999999999 141.96 172.9 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS C, QUANTIFICATION, INCLUDES REVERSE TRANSCRIPTION WHEN PERFORMED" 3068752203_1 CDM 306 RC 87522 HCPCS outpatient 452 339 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 406.8 90 999999999 352.56 429.4 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS C, QUANTIFICATION, INCLUDES REVERSE TRANSCRIPTION WHEN PERFORMED" 3068752203_1 CDM 306 RC 87522 HCPCS outpatient 452 339 AETNA MCR ADV AETNA MCR ADV 352.56 78 999999999 352.56 429.4 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS C, QUANTIFICATION, INCLUDES REVERSE TRANSCRIPTION WHEN PERFORMED" 3068752203_1 CDM 306 RC 87522 HCPCS outpatient 452 339 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 395.82 87.57 999999999 352.56 429.4 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS C, QUANTIFICATION, INCLUDES REVERSE TRANSCRIPTION WHEN PERFORMED" 3068752203_1 CDM 306 RC 87522 HCPCS outpatient 452 339 COORDINATED CARE MCAID COORDINATED CARE MCAID 384.52 85.07 999999999 352.56 429.4 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS C, QUANTIFICATION, INCLUDES REVERSE TRANSCRIPTION WHEN PERFORMED" 3068752203_1 CDM 306 RC 87522 HCPCS outpatient 452 339 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 384.52 85.07 999999999 352.56 429.4 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS C, QUANTIFICATION, INCLUDES REVERSE TRANSCRIPTION WHEN PERFORMED" 3068752203_1 CDM 306 RC 87522 HCPCS outpatient 452 339 MOLINA MCAID MOLINA MCAID 376.97 83.4 999999999 352.56 429.4 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS C, QUANTIFICATION, INCLUDES REVERSE TRANSCRIPTION WHEN PERFORMED" 3068752203_1 CDM 306 RC 87522 HCPCS outpatient 452 339 MOLINA MCR ADV MOLINA MCR ADV 402.28 89 999999999 352.56 429.4 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS C, QUANTIFICATION, INCLUDES REVERSE TRANSCRIPTION WHEN PERFORMED" 3068752203_1 CDM 306 RC 87522 HCPCS outpatient 452 339 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 402.28 89 999999999 352.56 429.4 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS C, QUANTIFICATION, INCLUDES REVERSE TRANSCRIPTION WHEN PERFORMED" 3068752203_1 CDM 306 RC 87522 HCPCS outpatient 452 339 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 402.28 89 999999999 352.56 429.4 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS C, QUANTIFICATION, INCLUDES REVERSE TRANSCRIPTION WHEN PERFORMED" 3068752203_1 CDM 306 RC 87522 HCPCS outpatient 452 339 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 406.8 90 999999999 352.56 429.4 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS C, QUANTIFICATION, INCLUDES REVERSE TRANSCRIPTION WHEN PERFORMED" 3068752203_1 CDM 306 RC 87522 HCPCS outpatient 452 339 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 429.4 95 999999999 352.56 429.4 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS C, QUANTIFICATION, INCLUDES REVERSE TRANSCRIPTION WHEN PERFORMED" 3068752203_1 CDM 306 RC 87522 HCPCS outpatient 452 339 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 429.4 95 999999999 352.56 429.4 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS C, QUANTIFICATION, INCLUDES REVERSE TRANSCRIPTION WHEN PERFORMED" 3068752203_1 CDM 306 RC 87522 HCPCS outpatient 452 339 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 402.28 89 999999999 352.56 429.4 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS C, QUANTIFICATION, INCLUDES REVERSE TRANSCRIPTION WHEN PERFORMED" 3068752203_1 CDM 306 RC 87522 HCPCS outpatient 452 339 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 397.76 88 999999999 352.56 429.4 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS C, QUANTIFICATION, INCLUDES REVERSE TRANSCRIPTION WHEN PERFORMED" 3068752203_1 CDM 306 RC 87522 HCPCS outpatient 452 339 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 402.28 89 999999999 352.56 429.4 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); NEISSERIA GONORRHOEAE, AMPLIFIED PROBE TECHNIQUE" 3068759102_1 CDM 306 RC 87591 HCPCS outpatient 152 114 MOLINA MCR ADV MOLINA MCR ADV 135.28 89 999999999 118.56 144.4 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); NEISSERIA GONORRHOEAE, AMPLIFIED PROBE TECHNIQUE" 3068759102_1 CDM 306 RC 87591 HCPCS outpatient 152 114 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 135.28 89 999999999 118.56 144.4 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); NEISSERIA GONORRHOEAE, AMPLIFIED PROBE TECHNIQUE" 3068759102_1 CDM 306 RC 87591 HCPCS outpatient 152 114 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 135.28 89 999999999 118.56 144.4 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); NEISSERIA GONORRHOEAE, AMPLIFIED PROBE TECHNIQUE" 3068759102_1 CDM 306 RC 87591 HCPCS outpatient 152 114 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 136.8 90 999999999 118.56 144.4 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); NEISSERIA GONORRHOEAE, AMPLIFIED PROBE TECHNIQUE" 3068759102_1 CDM 306 RC 87591 HCPCS outpatient 152 114 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 144.4 95 999999999 118.56 144.4 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); NEISSERIA GONORRHOEAE, AMPLIFIED PROBE TECHNIQUE" 3068759102_1 CDM 306 RC 87591 HCPCS outpatient 152 114 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 144.4 95 999999999 118.56 144.4 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); NEISSERIA GONORRHOEAE, AMPLIFIED PROBE TECHNIQUE" 3068759102_1 CDM 306 RC 87591 HCPCS outpatient 152 114 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 135.28 89 999999999 118.56 144.4 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); NEISSERIA GONORRHOEAE, AMPLIFIED PROBE TECHNIQUE" 3068759102_1 CDM 306 RC 87591 HCPCS outpatient 152 114 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 133.76 88 999999999 118.56 144.4 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); NEISSERIA GONORRHOEAE, AMPLIFIED PROBE TECHNIQUE" 3068759102_1 CDM 306 RC 87591 HCPCS outpatient 152 114 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 135.28 89 999999999 118.56 144.4 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); NEISSERIA GONORRHOEAE, AMPLIFIED PROBE TECHNIQUE" 3068759102_1 CDM 306 RC 87591 HCPCS outpatient 152 114 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 136.8 90 999999999 118.56 144.4 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); NEISSERIA GONORRHOEAE, AMPLIFIED PROBE TECHNIQUE" 3068759102_1 CDM 306 RC 87591 HCPCS outpatient 152 114 AETNA MCR ADV AETNA MCR ADV 118.56 78 999999999 118.56 144.4 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); NEISSERIA GONORRHOEAE, AMPLIFIED PROBE TECHNIQUE" 3068759102_1 CDM 306 RC 87591 HCPCS outpatient 152 114 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 133.11 87.57 999999999 118.56 144.4 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); NEISSERIA GONORRHOEAE, AMPLIFIED PROBE TECHNIQUE" 3068759102_1 CDM 306 RC 87591 HCPCS outpatient 152 114 COORDINATED CARE MCAID COORDINATED CARE MCAID 129.31 85.07 999999999 118.56 144.4 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); NEISSERIA GONORRHOEAE, AMPLIFIED PROBE TECHNIQUE" 3068759102_1 CDM 306 RC 87591 HCPCS outpatient 152 114 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 129.31 85.07 999999999 118.56 144.4 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); NEISSERIA GONORRHOEAE, AMPLIFIED PROBE TECHNIQUE" 3068759102_1 CDM 306 RC 87591 HCPCS outpatient 152 114 MOLINA MCAID MOLINA MCAID 126.77 83.4 999999999 118.56 144.4 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); RESPIRATORY SYNCYTIAL VIRUS, AMPLIFIED PROBE TECHNIQUE" 3068763401_1 CDM 306 RC 87634 HCPCS outpatient 140 105 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 126 90 999999999 109.2 133 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); RESPIRATORY SYNCYTIAL VIRUS, AMPLIFIED PROBE TECHNIQUE" 3068763401_1 CDM 306 RC 87634 HCPCS outpatient 140 105 AETNA MCR ADV AETNA MCR ADV 109.2 78 999999999 109.2 133 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); RESPIRATORY SYNCYTIAL VIRUS, AMPLIFIED PROBE TECHNIQUE" 3068763401_1 CDM 306 RC 87634 HCPCS outpatient 140 105 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 122.6 87.57 999999999 109.2 133 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); RESPIRATORY SYNCYTIAL VIRUS, AMPLIFIED PROBE TECHNIQUE" 3068763401_1 CDM 306 RC 87634 HCPCS outpatient 140 105 COORDINATED CARE MCAID COORDINATED CARE MCAID 119.1 85.07 999999999 109.2 133 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); RESPIRATORY SYNCYTIAL VIRUS, AMPLIFIED PROBE TECHNIQUE" 3068763401_1 CDM 306 RC 87634 HCPCS outpatient 140 105 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 119.1 85.07 999999999 109.2 133 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); RESPIRATORY SYNCYTIAL VIRUS, AMPLIFIED PROBE TECHNIQUE" 3068763401_1 CDM 306 RC 87634 HCPCS outpatient 140 105 MOLINA MCAID MOLINA MCAID 116.76 83.4 999999999 109.2 133 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); RESPIRATORY SYNCYTIAL VIRUS, AMPLIFIED PROBE TECHNIQUE" 3068763401_1 CDM 306 RC 87634 HCPCS outpatient 140 105 MOLINA MCR ADV MOLINA MCR ADV 124.6 89 999999999 109.2 133 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); RESPIRATORY SYNCYTIAL VIRUS, AMPLIFIED PROBE TECHNIQUE" 3068763401_1 CDM 306 RC 87634 HCPCS outpatient 140 105 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 124.6 89 999999999 109.2 133 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); RESPIRATORY SYNCYTIAL VIRUS, AMPLIFIED PROBE TECHNIQUE" 3068763401_1 CDM 306 RC 87634 HCPCS outpatient 140 105 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 124.6 89 999999999 109.2 133 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); RESPIRATORY SYNCYTIAL VIRUS, AMPLIFIED PROBE TECHNIQUE" 3068763401_1 CDM 306 RC 87634 HCPCS outpatient 140 105 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 126 90 999999999 109.2 133 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); RESPIRATORY SYNCYTIAL VIRUS, AMPLIFIED PROBE TECHNIQUE" 3068763401_1 CDM 306 RC 87634 HCPCS outpatient 140 105 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 133 95 999999999 109.2 133 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); RESPIRATORY SYNCYTIAL VIRUS, AMPLIFIED PROBE TECHNIQUE" 3068763401_1 CDM 306 RC 87634 HCPCS outpatient 140 105 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 133 95 999999999 109.2 133 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); RESPIRATORY SYNCYTIAL VIRUS, AMPLIFIED PROBE TECHNIQUE" 3068763401_1 CDM 306 RC 87634 HCPCS outpatient 140 105 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 124.6 89 999999999 109.2 133 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); RESPIRATORY SYNCYTIAL VIRUS, AMPLIFIED PROBE TECHNIQUE" 3068763401_1 CDM 306 RC 87634 HCPCS outpatient 140 105 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 123.2 88 999999999 109.2 133 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); RESPIRATORY SYNCYTIAL VIRUS, AMPLIFIED PROBE TECHNIQUE" 3068763401_1 CDM 306 RC 87634 HCPCS outpatient 140 105 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 124.6 89 999999999 109.2 133 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]), AMPLIFIED PROBE TECHNIQUE" 3068763501_1 CDM 306 RC 87635 HCPCS outpatient 122 91.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 109.8 90 999999999 95.16 115.9 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]), AMPLIFIED PROBE TECHNIQUE" 3068763501_1 CDM 306 RC 87635 HCPCS outpatient 122 91.5 AETNA MCR ADV AETNA MCR ADV 95.16 78 999999999 95.16 115.9 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]), AMPLIFIED PROBE TECHNIQUE" 3068763501_1 CDM 306 RC 87635 HCPCS outpatient 122 91.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 106.84 87.57 999999999 95.16 115.9 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]), AMPLIFIED PROBE TECHNIQUE" 3068763501_1 CDM 306 RC 87635 HCPCS outpatient 122 91.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 103.79 85.07 999999999 95.16 115.9 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]), AMPLIFIED PROBE TECHNIQUE" 3068763501_1 CDM 306 RC 87635 HCPCS outpatient 122 91.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 103.79 85.07 999999999 95.16 115.9 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]), AMPLIFIED PROBE TECHNIQUE" 3068763501_1 CDM 306 RC 87635 HCPCS outpatient 122 91.5 MOLINA MCAID MOLINA MCAID 101.75 83.4 999999999 95.16 115.9 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]), AMPLIFIED PROBE TECHNIQUE" 3068763501_1 CDM 306 RC 87635 HCPCS outpatient 122 91.5 MOLINA MCR ADV MOLINA MCR ADV 108.58 89 999999999 95.16 115.9 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]), AMPLIFIED PROBE TECHNIQUE" 3068763501_1 CDM 306 RC 87635 HCPCS outpatient 122 91.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 108.58 89 999999999 95.16 115.9 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]), AMPLIFIED PROBE TECHNIQUE" 3068763501_1 CDM 306 RC 87635 HCPCS outpatient 122 91.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 108.58 89 999999999 95.16 115.9 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]), AMPLIFIED PROBE TECHNIQUE" 3068763501_1 CDM 306 RC 87635 HCPCS outpatient 122 91.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 109.8 90 999999999 95.16 115.9 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]), AMPLIFIED PROBE TECHNIQUE" 3068763501_1 CDM 306 RC 87635 HCPCS outpatient 122 91.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 115.9 95 999999999 95.16 115.9 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]), AMPLIFIED PROBE TECHNIQUE" 3068763501_1 CDM 306 RC 87635 HCPCS outpatient 122 91.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 115.9 95 999999999 95.16 115.9 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]), AMPLIFIED PROBE TECHNIQUE" 3068763501_1 CDM 306 RC 87635 HCPCS outpatient 122 91.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 108.58 89 999999999 95.16 115.9 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]), AMPLIFIED PROBE TECHNIQUE" 3068763501_1 CDM 306 RC 87635 HCPCS outpatient 122 91.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 107.36 88 999999999 95.16 115.9 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]), AMPLIFIED PROBE TECHNIQUE" 3068763501_1 CDM 306 RC 87635 HCPCS outpatient 122 91.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 108.58 89 999999999 95.16 115.9 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STAPHYLOCOCCUS AUREUS, METHICILLIN RESISTANT, AMPLIFIED PROBE TECHNIQUE" 3068764101_1 CDM 306 RC 87641 HCPCS outpatient 237 177.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 213.3 90 999999999 184.86 225.15 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STAPHYLOCOCCUS AUREUS, METHICILLIN RESISTANT, AMPLIFIED PROBE TECHNIQUE" 3068764101_1 CDM 306 RC 87641 HCPCS outpatient 237 177.75 AETNA MCR ADV AETNA MCR ADV 184.86 78 999999999 184.86 225.15 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STAPHYLOCOCCUS AUREUS, METHICILLIN RESISTANT, AMPLIFIED PROBE TECHNIQUE" 3068764101_1 CDM 306 RC 87641 HCPCS outpatient 237 177.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 207.54 87.57 999999999 184.86 225.15 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STAPHYLOCOCCUS AUREUS, METHICILLIN RESISTANT, AMPLIFIED PROBE TECHNIQUE" 3068764101_1 CDM 306 RC 87641 HCPCS outpatient 237 177.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 201.62 85.07 999999999 184.86 225.15 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STAPHYLOCOCCUS AUREUS, METHICILLIN RESISTANT, AMPLIFIED PROBE TECHNIQUE" 3068764101_1 CDM 306 RC 87641 HCPCS outpatient 237 177.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 201.62 85.07 999999999 184.86 225.15 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STAPHYLOCOCCUS AUREUS, METHICILLIN RESISTANT, AMPLIFIED PROBE TECHNIQUE" 3068764101_1 CDM 306 RC 87641 HCPCS outpatient 237 177.75 MOLINA MCAID MOLINA MCAID 197.66 83.4 999999999 184.86 225.15 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STAPHYLOCOCCUS AUREUS, METHICILLIN RESISTANT, AMPLIFIED PROBE TECHNIQUE" 3068764101_1 CDM 306 RC 87641 HCPCS outpatient 237 177.75 MOLINA MCR ADV MOLINA MCR ADV 210.93 89 999999999 184.86 225.15 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STAPHYLOCOCCUS AUREUS, METHICILLIN RESISTANT, AMPLIFIED PROBE TECHNIQUE" 3068764101_1 CDM 306 RC 87641 HCPCS outpatient 237 177.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 210.93 89 999999999 184.86 225.15 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STAPHYLOCOCCUS AUREUS, METHICILLIN RESISTANT, AMPLIFIED PROBE TECHNIQUE" 3068764101_1 CDM 306 RC 87641 HCPCS outpatient 237 177.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 210.93 89 999999999 184.86 225.15 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STAPHYLOCOCCUS AUREUS, METHICILLIN RESISTANT, AMPLIFIED PROBE TECHNIQUE" 3068764101_1 CDM 306 RC 87641 HCPCS outpatient 237 177.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 213.3 90 999999999 184.86 225.15 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STAPHYLOCOCCUS AUREUS, METHICILLIN RESISTANT, AMPLIFIED PROBE TECHNIQUE" 3068764101_1 CDM 306 RC 87641 HCPCS outpatient 237 177.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 225.15 95 999999999 184.86 225.15 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STAPHYLOCOCCUS AUREUS, METHICILLIN RESISTANT, AMPLIFIED PROBE TECHNIQUE" 3068764101_1 CDM 306 RC 87641 HCPCS outpatient 237 177.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 225.15 95 999999999 184.86 225.15 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STAPHYLOCOCCUS AUREUS, METHICILLIN RESISTANT, AMPLIFIED PROBE TECHNIQUE" 3068764101_1 CDM 306 RC 87641 HCPCS outpatient 237 177.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 210.93 89 999999999 184.86 225.15 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STAPHYLOCOCCUS AUREUS, METHICILLIN RESISTANT, AMPLIFIED PROBE TECHNIQUE" 3068764101_1 CDM 306 RC 87641 HCPCS outpatient 237 177.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 208.56 88 999999999 184.86 225.15 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STAPHYLOCOCCUS AUREUS, METHICILLIN RESISTANT, AMPLIFIED PROBE TECHNIQUE" 3068764101_1 CDM 306 RC 87641 HCPCS outpatient 237 177.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 210.93 89 999999999 184.86 225.15 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP A, AMPLIFIED PROBE TECHNIQUE" 3068765101_1 CDM 306 RC 87651 HCPCS outpatient 140 105 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 126 90 999999999 109.2 133 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP A, AMPLIFIED PROBE TECHNIQUE" 3068765101_1 CDM 306 RC 87651 HCPCS outpatient 140 105 AETNA MCR ADV AETNA MCR ADV 109.2 78 999999999 109.2 133 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP A, AMPLIFIED PROBE TECHNIQUE" 3068765101_1 CDM 306 RC 87651 HCPCS outpatient 140 105 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 122.6 87.57 999999999 109.2 133 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP A, AMPLIFIED PROBE TECHNIQUE" 3068765101_1 CDM 306 RC 87651 HCPCS outpatient 140 105 COORDINATED CARE MCAID COORDINATED CARE MCAID 119.1 85.07 999999999 109.2 133 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP A, AMPLIFIED PROBE TECHNIQUE" 3068765101_1 CDM 306 RC 87651 HCPCS outpatient 140 105 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 119.1 85.07 999999999 109.2 133 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP A, AMPLIFIED PROBE TECHNIQUE" 3068765101_1 CDM 306 RC 87651 HCPCS outpatient 140 105 MOLINA MCAID MOLINA MCAID 116.76 83.4 999999999 109.2 133 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP A, AMPLIFIED PROBE TECHNIQUE" 3068765101_1 CDM 306 RC 87651 HCPCS outpatient 140 105 MOLINA MCR ADV MOLINA MCR ADV 124.6 89 999999999 109.2 133 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP A, AMPLIFIED PROBE TECHNIQUE" 3068765101_1 CDM 306 RC 87651 HCPCS outpatient 140 105 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 124.6 89 999999999 109.2 133 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP A, AMPLIFIED PROBE TECHNIQUE" 3068765101_1 CDM 306 RC 87651 HCPCS outpatient 140 105 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 124.6 89 999999999 109.2 133 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP A, AMPLIFIED PROBE TECHNIQUE" 3068765101_1 CDM 306 RC 87651 HCPCS outpatient 140 105 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 126 90 999999999 109.2 133 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP A, AMPLIFIED PROBE TECHNIQUE" 3068765101_1 CDM 306 RC 87651 HCPCS outpatient 140 105 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 133 95 999999999 109.2 133 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP A, AMPLIFIED PROBE TECHNIQUE" 3068765101_1 CDM 306 RC 87651 HCPCS outpatient 140 105 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 133 95 999999999 109.2 133 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP A, AMPLIFIED PROBE TECHNIQUE" 3068765101_1 CDM 306 RC 87651 HCPCS outpatient 140 105 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 124.6 89 999999999 109.2 133 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP A, AMPLIFIED PROBE TECHNIQUE" 3068765101_1 CDM 306 RC 87651 HCPCS outpatient 140 105 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 123.2 88 999999999 109.2 133 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP A, AMPLIFIED PROBE TECHNIQUE" 3068765101_1 CDM 306 RC 87651 HCPCS outpatient 140 105 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 124.6 89 999999999 109.2 133 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT OTHERWISE SPECIFIED; QUANTIFICATION, EACH ORGANISM" 3068779901_1 CDM 306 RC 87799 HCPCS outpatient 389 291.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 350.1 90 999999999 303.42 369.55 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT OTHERWISE SPECIFIED; QUANTIFICATION, EACH ORGANISM" 3068779901_1 CDM 306 RC 87799 HCPCS outpatient 389 291.75 AETNA MCR ADV AETNA MCR ADV 303.42 78 999999999 303.42 369.55 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT OTHERWISE SPECIFIED; QUANTIFICATION, EACH ORGANISM" 3068779901_1 CDM 306 RC 87799 HCPCS outpatient 389 291.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 340.65 87.57 999999999 303.42 369.55 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT OTHERWISE SPECIFIED; QUANTIFICATION, EACH ORGANISM" 3068779901_1 CDM 306 RC 87799 HCPCS outpatient 389 291.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 330.92 85.07 999999999 303.42 369.55 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT OTHERWISE SPECIFIED; QUANTIFICATION, EACH ORGANISM" 3068779901_1 CDM 306 RC 87799 HCPCS outpatient 389 291.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 330.92 85.07 999999999 303.42 369.55 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT OTHERWISE SPECIFIED; QUANTIFICATION, EACH ORGANISM" 3068779901_1 CDM 306 RC 87799 HCPCS outpatient 389 291.75 MOLINA MCAID MOLINA MCAID 324.43 83.4 999999999 303.42 369.55 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT OTHERWISE SPECIFIED; QUANTIFICATION, EACH ORGANISM" 3068779901_1 CDM 306 RC 87799 HCPCS outpatient 389 291.75 MOLINA MCR ADV MOLINA MCR ADV 346.21 89 999999999 303.42 369.55 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT OTHERWISE SPECIFIED; QUANTIFICATION, EACH ORGANISM" 3068779901_1 CDM 306 RC 87799 HCPCS outpatient 389 291.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 346.21 89 999999999 303.42 369.55 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT OTHERWISE SPECIFIED; QUANTIFICATION, EACH ORGANISM" 3068779901_1 CDM 306 RC 87799 HCPCS outpatient 389 291.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 346.21 89 999999999 303.42 369.55 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT OTHERWISE SPECIFIED; QUANTIFICATION, EACH ORGANISM" 3068779901_1 CDM 306 RC 87799 HCPCS outpatient 389 291.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 350.1 90 999999999 303.42 369.55 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT OTHERWISE SPECIFIED; QUANTIFICATION, EACH ORGANISM" 3068779901_1 CDM 306 RC 87799 HCPCS outpatient 389 291.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 369.55 95 999999999 303.42 369.55 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT OTHERWISE SPECIFIED; QUANTIFICATION, EACH ORGANISM" 3068779901_1 CDM 306 RC 87799 HCPCS outpatient 389 291.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 369.55 95 999999999 303.42 369.55 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT OTHERWISE SPECIFIED; QUANTIFICATION, EACH ORGANISM" 3068779901_1 CDM 306 RC 87799 HCPCS outpatient 389 291.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 346.21 89 999999999 303.42 369.55 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT OTHERWISE SPECIFIED; QUANTIFICATION, EACH ORGANISM" 3068779901_1 CDM 306 RC 87799 HCPCS outpatient 389 291.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 342.32 88 999999999 303.42 369.55 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT OTHERWISE SPECIFIED; QUANTIFICATION, EACH ORGANISM" 3068779901_1 CDM 306 RC 87799 HCPCS outpatient 389 291.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 346.21 89 999999999 303.42 369.55 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 3068788001_1 CDM 306 RC 87880 HCPCS outpatient 75 56.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 67.5 90 999999999 58.5 71.25 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 3068788001_1 CDM 306 RC 87880 HCPCS outpatient 75 56.25 AETNA MCR ADV AETNA MCR ADV 58.5 78 999999999 58.5 71.25 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 3068788001_1 CDM 306 RC 87880 HCPCS outpatient 75 56.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 65.68 87.57 999999999 58.5 71.25 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 3068788001_1 CDM 306 RC 87880 HCPCS outpatient 75 56.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 63.8 85.07 999999999 58.5 71.25 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 3068788001_1 CDM 306 RC 87880 HCPCS outpatient 75 56.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 63.8 85.07 999999999 58.5 71.25 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 3068788001_1 CDM 306 RC 87880 HCPCS outpatient 75 56.25 MOLINA MCAID MOLINA MCAID 62.55 83.4 999999999 58.5 71.25 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 3068788001_1 CDM 306 RC 87880 HCPCS outpatient 75 56.25 MOLINA MCR ADV MOLINA MCR ADV 66.75 89 999999999 58.5 71.25 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 3068788001_1 CDM 306 RC 87880 HCPCS outpatient 75 56.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 66.75 89 999999999 58.5 71.25 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 3068788001_1 CDM 306 RC 87880 HCPCS outpatient 75 56.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 66.75 89 999999999 58.5 71.25 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 3068788001_1 CDM 306 RC 87880 HCPCS outpatient 75 56.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 67.5 90 999999999 58.5 71.25 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 3068788001_1 CDM 306 RC 87880 HCPCS outpatient 75 56.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 71.25 95 999999999 58.5 71.25 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 3068788001_1 CDM 306 RC 87880 HCPCS outpatient 75 56.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 71.25 95 999999999 58.5 71.25 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 3068788001_1 CDM 306 RC 87880 HCPCS outpatient 75 56.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 66.75 89 999999999 58.5 71.25 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 3068788001_1 CDM 306 RC 87880 HCPCS outpatient 75 56.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 66 88 999999999 58.5 71.25 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 3068788001_1 CDM 306 RC 87880 HCPCS outpatient 75 56.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 66.75 89 999999999 58.5 71.25 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; NOT OTHERWISE SPECIFIED" 3068789906_1 CDM 306 RC 87899 HCPCS outpatient 103 77.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 92.7 90 999999999 80.34 97.85 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; NOT OTHERWISE SPECIFIED" 3068789906_1 CDM 306 RC 87899 HCPCS outpatient 103 77.25 AETNA MCR ADV AETNA MCR ADV 80.34 78 999999999 80.34 97.85 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; NOT OTHERWISE SPECIFIED" 3068789906_1 CDM 306 RC 87899 HCPCS outpatient 103 77.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 90.2 87.57 999999999 80.34 97.85 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; NOT OTHERWISE SPECIFIED" 3068789906_1 CDM 306 RC 87899 HCPCS outpatient 103 77.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 87.62 85.07 999999999 80.34 97.85 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; NOT OTHERWISE SPECIFIED" 3068789906_1 CDM 306 RC 87899 HCPCS outpatient 103 77.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 87.62 85.07 999999999 80.34 97.85 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; NOT OTHERWISE SPECIFIED" 3068789906_1 CDM 306 RC 87899 HCPCS outpatient 103 77.25 MOLINA MCAID MOLINA MCAID 85.9 83.4 999999999 80.34 97.85 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; NOT OTHERWISE SPECIFIED" 3068789906_1 CDM 306 RC 87899 HCPCS outpatient 103 77.25 MOLINA MCR ADV MOLINA MCR ADV 91.67 89 999999999 80.34 97.85 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; NOT OTHERWISE SPECIFIED" 3068789906_1 CDM 306 RC 87899 HCPCS outpatient 103 77.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 91.67 89 999999999 80.34 97.85 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; NOT OTHERWISE SPECIFIED" 3068789906_1 CDM 306 RC 87899 HCPCS outpatient 103 77.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 91.67 89 999999999 80.34 97.85 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; NOT OTHERWISE SPECIFIED" 3068789906_1 CDM 306 RC 87899 HCPCS outpatient 103 77.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 92.7 90 999999999 80.34 97.85 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; NOT OTHERWISE SPECIFIED" 3068789906_1 CDM 306 RC 87899 HCPCS outpatient 103 77.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 97.85 95 999999999 80.34 97.85 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; NOT OTHERWISE SPECIFIED" 3068789906_1 CDM 306 RC 87899 HCPCS outpatient 103 77.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 97.85 95 999999999 80.34 97.85 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; NOT OTHERWISE SPECIFIED" 3068789906_1 CDM 306 RC 87899 HCPCS outpatient 103 77.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 91.67 89 999999999 80.34 97.85 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; NOT OTHERWISE SPECIFIED" 3068789906_1 CDM 306 RC 87899 HCPCS outpatient 103 77.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 90.64 88 999999999 80.34 97.85 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; NOT OTHERWISE SPECIFIED" 3068789906_1 CDM 306 RC 87899 HCPCS outpatient 103 77.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 91.67 89 999999999 80.34 97.85 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY" 3078100101_1 CDM 307 RC 81001 HCPCS outpatient 64 48 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 57.6 90 999999999 49.92 60.8 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY" 3078100101_1 CDM 307 RC 81001 HCPCS outpatient 64 48 AETNA MCR ADV AETNA MCR ADV 49.92 78 999999999 49.92 60.8 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY" 3078100101_1 CDM 307 RC 81001 HCPCS outpatient 64 48 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 56.04 87.57 999999999 49.92 60.8 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY" 3078100101_1 CDM 307 RC 81001 HCPCS outpatient 64 48 COORDINATED CARE MCAID COORDINATED CARE MCAID 54.44 85.07 999999999 49.92 60.8 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY" 3078100101_1 CDM 307 RC 81001 HCPCS outpatient 64 48 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 54.44 85.07 999999999 49.92 60.8 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY" 3078100101_1 CDM 307 RC 81001 HCPCS outpatient 64 48 MOLINA MCAID MOLINA MCAID 53.38 83.4 999999999 49.92 60.8 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY" 3078100101_1 CDM 307 RC 81001 HCPCS outpatient 64 48 MOLINA MCR ADV MOLINA MCR ADV 56.96 89 999999999 49.92 60.8 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY" 3078100101_1 CDM 307 RC 81001 HCPCS outpatient 64 48 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 56.96 89 999999999 49.92 60.8 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY" 3078100101_1 CDM 307 RC 81001 HCPCS outpatient 64 48 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 56.96 89 999999999 49.92 60.8 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY" 3078100101_1 CDM 307 RC 81001 HCPCS outpatient 64 48 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 57.6 90 999999999 49.92 60.8 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY" 3078100101_1 CDM 307 RC 81001 HCPCS outpatient 64 48 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 60.8 95 999999999 49.92 60.8 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY" 3078100101_1 CDM 307 RC 81001 HCPCS outpatient 64 48 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 60.8 95 999999999 49.92 60.8 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY" 3078100101_1 CDM 307 RC 81001 HCPCS outpatient 64 48 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 56.96 89 999999999 49.92 60.8 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY" 3078100101_1 CDM 307 RC 81001 HCPCS outpatient 64 48 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 56.32 88 999999999 49.92 60.8 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY" 3078100101_1 CDM 307 RC 81001 HCPCS outpatient 64 48 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 56.96 89 999999999 49.92 60.8 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 3078100301_1 CDM 307 RC 81003 HCPCS outpatient 43 32.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 38.7 90 999999999 33.54 40.85 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 3078100301_1 CDM 307 RC 81003 HCPCS outpatient 43 32.25 AETNA MCR ADV AETNA MCR ADV 33.54 78 999999999 33.54 40.85 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 3078100301_1 CDM 307 RC 81003 HCPCS outpatient 43 32.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 37.66 87.57 999999999 33.54 40.85 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 3078100301_1 CDM 307 RC 81003 HCPCS outpatient 43 32.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 36.58 85.07 999999999 33.54 40.85 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 3078100301_1 CDM 307 RC 81003 HCPCS outpatient 43 32.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 36.58 85.07 999999999 33.54 40.85 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 3078100301_1 CDM 307 RC 81003 HCPCS outpatient 43 32.25 MOLINA MCAID MOLINA MCAID 35.86 83.4 999999999 33.54 40.85 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 3078100301_1 CDM 307 RC 81003 HCPCS outpatient 43 32.25 MOLINA MCR ADV MOLINA MCR ADV 38.27 89 999999999 33.54 40.85 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 3078100301_1 CDM 307 RC 81003 HCPCS outpatient 43 32.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 38.27 89 999999999 33.54 40.85 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 3078100301_1 CDM 307 RC 81003 HCPCS outpatient 43 32.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 38.27 89 999999999 33.54 40.85 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 3078100301_1 CDM 307 RC 81003 HCPCS outpatient 43 32.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 38.7 90 999999999 33.54 40.85 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 3078100301_1 CDM 307 RC 81003 HCPCS outpatient 43 32.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 40.85 95 999999999 33.54 40.85 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 3078100301_1 CDM 307 RC 81003 HCPCS outpatient 43 32.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 40.85 95 999999999 33.54 40.85 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 3078100301_1 CDM 307 RC 81003 HCPCS outpatient 43 32.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 38.27 89 999999999 33.54 40.85 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 3078100301_1 CDM 307 RC 81003 HCPCS outpatient 43 32.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 37.84 88 999999999 33.54 40.85 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 3078100301_1 CDM 307 RC 81003 HCPCS outpatient 43 32.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 38.27 89 999999999 33.54 40.85 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 3078100502_1 CDM 307 RC 81005 HCPCS outpatient 57 42.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 51.3 90 999999999 44.46 54.15 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 3078100502_1 CDM 307 RC 81005 HCPCS outpatient 57 42.75 AETNA MCR ADV AETNA MCR ADV 44.46 78 999999999 44.46 54.15 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 3078100502_1 CDM 307 RC 81005 HCPCS outpatient 57 42.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 49.91 87.57 999999999 44.46 54.15 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 3078100502_1 CDM 307 RC 81005 HCPCS outpatient 57 42.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 48.49 85.07 999999999 44.46 54.15 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 3078100502_1 CDM 307 RC 81005 HCPCS outpatient 57 42.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 48.49 85.07 999999999 44.46 54.15 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 3078100502_1 CDM 307 RC 81005 HCPCS outpatient 57 42.75 MOLINA MCAID MOLINA MCAID 47.54 83.4 999999999 44.46 54.15 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 3078100502_1 CDM 307 RC 81005 HCPCS outpatient 57 42.75 MOLINA MCR ADV MOLINA MCR ADV 50.73 89 999999999 44.46 54.15 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 3078100502_1 CDM 307 RC 81005 HCPCS outpatient 57 42.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50.73 89 999999999 44.46 54.15 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 3078100502_1 CDM 307 RC 81005 HCPCS outpatient 57 42.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50.73 89 999999999 44.46 54.15 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 3078100502_1 CDM 307 RC 81005 HCPCS outpatient 57 42.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 51.3 90 999999999 44.46 54.15 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 3078100502_1 CDM 307 RC 81005 HCPCS outpatient 57 42.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 54.15 95 999999999 44.46 54.15 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 3078100502_1 CDM 307 RC 81005 HCPCS outpatient 57 42.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 54.15 95 999999999 44.46 54.15 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 3078100502_1 CDM 307 RC 81005 HCPCS outpatient 57 42.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50.73 89 999999999 44.46 54.15 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 3078100502_1 CDM 307 RC 81005 HCPCS outpatient 57 42.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50.16 88 999999999 44.46 54.15 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 3078100502_1 CDM 307 RC 81005 HCPCS outpatient 57 42.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50.73 89 999999999 44.46 54.15 percent of total billed charges URINALYSIS; MICROSCOPIC ONLY 3078101501_1 CDM 307 RC 81015 HCPCS outpatient 43 32.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 38.7 90 999999999 33.54 40.85 percent of total billed charges URINALYSIS; MICROSCOPIC ONLY 3078101501_1 CDM 307 RC 81015 HCPCS outpatient 43 32.25 AETNA MCR ADV AETNA MCR ADV 33.54 78 999999999 33.54 40.85 percent of total billed charges URINALYSIS; MICROSCOPIC ONLY 3078101501_1 CDM 307 RC 81015 HCPCS outpatient 43 32.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 37.66 87.57 999999999 33.54 40.85 percent of total billed charges URINALYSIS; MICROSCOPIC ONLY 3078101501_1 CDM 307 RC 81015 HCPCS outpatient 43 32.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 36.58 85.07 999999999 33.54 40.85 percent of total billed charges URINALYSIS; MICROSCOPIC ONLY 3078101501_1 CDM 307 RC 81015 HCPCS outpatient 43 32.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 36.58 85.07 999999999 33.54 40.85 percent of total billed charges URINALYSIS; MICROSCOPIC ONLY 3078101501_1 CDM 307 RC 81015 HCPCS outpatient 43 32.25 MOLINA MCAID MOLINA MCAID 35.86 83.4 999999999 33.54 40.85 percent of total billed charges URINALYSIS; MICROSCOPIC ONLY 3078101501_1 CDM 307 RC 81015 HCPCS outpatient 43 32.25 MOLINA MCR ADV MOLINA MCR ADV 38.27 89 999999999 33.54 40.85 percent of total billed charges URINALYSIS; MICROSCOPIC ONLY 3078101501_1 CDM 307 RC 81015 HCPCS outpatient 43 32.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 38.27 89 999999999 33.54 40.85 percent of total billed charges URINALYSIS; MICROSCOPIC ONLY 3078101501_1 CDM 307 RC 81015 HCPCS outpatient 43 32.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 38.27 89 999999999 33.54 40.85 percent of total billed charges URINALYSIS; MICROSCOPIC ONLY 3078101501_1 CDM 307 RC 81015 HCPCS outpatient 43 32.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 38.7 90 999999999 33.54 40.85 percent of total billed charges URINALYSIS; MICROSCOPIC ONLY 3078101501_1 CDM 307 RC 81015 HCPCS outpatient 43 32.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 40.85 95 999999999 33.54 40.85 percent of total billed charges URINALYSIS; MICROSCOPIC ONLY 3078101501_1 CDM 307 RC 81015 HCPCS outpatient 43 32.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 40.85 95 999999999 33.54 40.85 percent of total billed charges URINALYSIS; MICROSCOPIC ONLY 3078101501_1 CDM 307 RC 81015 HCPCS outpatient 43 32.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 38.27 89 999999999 33.54 40.85 percent of total billed charges URINALYSIS; MICROSCOPIC ONLY 3078101501_1 CDM 307 RC 81015 HCPCS outpatient 43 32.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 37.84 88 999999999 33.54 40.85 percent of total billed charges URINALYSIS; MICROSCOPIC ONLY 3078101501_1 CDM 307 RC 81015 HCPCS outpatient 43 32.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 38.27 89 999999999 33.54 40.85 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102501_1 CDM 307 RC 81025 HCPCS outpatient 81 60.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 72.9 90 999999999 63.18 76.95 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102501_1 CDM 307 RC 81025 HCPCS outpatient 81 60.75 AETNA MCR ADV AETNA MCR ADV 63.18 78 999999999 63.18 76.95 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102501_1 CDM 307 RC 81025 HCPCS outpatient 81 60.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 70.93 87.57 999999999 63.18 76.95 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102501_1 CDM 307 RC 81025 HCPCS outpatient 81 60.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 68.91 85.07 999999999 63.18 76.95 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102501_1 CDM 307 RC 81025 HCPCS outpatient 81 60.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 68.91 85.07 999999999 63.18 76.95 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102501_1 CDM 307 RC 81025 HCPCS outpatient 81 60.75 MOLINA MCAID MOLINA MCAID 67.55 83.4 999999999 63.18 76.95 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102501_1 CDM 307 RC 81025 HCPCS outpatient 81 60.75 MOLINA MCR ADV MOLINA MCR ADV 72.09 89 999999999 63.18 76.95 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102501_1 CDM 307 RC 81025 HCPCS outpatient 81 60.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 72.09 89 999999999 63.18 76.95 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102501_1 CDM 307 RC 81025 HCPCS outpatient 81 60.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 72.09 89 999999999 63.18 76.95 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102501_1 CDM 307 RC 81025 HCPCS outpatient 81 60.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 72.9 90 999999999 63.18 76.95 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102501_1 CDM 307 RC 81025 HCPCS outpatient 81 60.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 76.95 95 999999999 63.18 76.95 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102501_1 CDM 307 RC 81025 HCPCS outpatient 81 60.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 76.95 95 999999999 63.18 76.95 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102501_1 CDM 307 RC 81025 HCPCS outpatient 81 60.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 72.09 89 999999999 63.18 76.95 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102501_1 CDM 307 RC 81025 HCPCS outpatient 81 60.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 71.28 88 999999999 63.18 76.95 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102501_1 CDM 307 RC 81025 HCPCS outpatient 81 60.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 72.09 89 999999999 63.18 76.95 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102501_2 CDM 307 RC 81025 HCPCS outpatient 81 60.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 72.9 90 999999999 63.18 76.95 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102501_2 CDM 307 RC 81025 HCPCS outpatient 81 60.75 AETNA MCR ADV AETNA MCR ADV 63.18 78 999999999 63.18 76.95 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102501_2 CDM 307 RC 81025 HCPCS outpatient 81 60.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 70.93 87.57 999999999 63.18 76.95 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102501_2 CDM 307 RC 81025 HCPCS outpatient 81 60.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 68.91 85.07 999999999 63.18 76.95 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102501_2 CDM 307 RC 81025 HCPCS outpatient 81 60.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 68.91 85.07 999999999 63.18 76.95 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102501_2 CDM 307 RC 81025 HCPCS outpatient 81 60.75 MOLINA MCAID MOLINA MCAID 67.55 83.4 999999999 63.18 76.95 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102501_2 CDM 307 RC 81025 HCPCS outpatient 81 60.75 MOLINA MCR ADV MOLINA MCR ADV 72.09 89 999999999 63.18 76.95 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102501_2 CDM 307 RC 81025 HCPCS outpatient 81 60.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 72.09 89 999999999 63.18 76.95 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102501_2 CDM 307 RC 81025 HCPCS outpatient 81 60.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 72.09 89 999999999 63.18 76.95 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102501_2 CDM 307 RC 81025 HCPCS outpatient 81 60.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 72.9 90 999999999 63.18 76.95 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102501_2 CDM 307 RC 81025 HCPCS outpatient 81 60.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 76.95 95 999999999 63.18 76.95 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102501_2 CDM 307 RC 81025 HCPCS outpatient 81 60.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 76.95 95 999999999 63.18 76.95 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102501_2 CDM 307 RC 81025 HCPCS outpatient 81 60.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 72.09 89 999999999 63.18 76.95 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102501_2 CDM 307 RC 81025 HCPCS outpatient 81 60.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 71.28 88 999999999 63.18 76.95 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102501_2 CDM 307 RC 81025 HCPCS outpatient 81 60.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 72.09 89 999999999 63.18 76.95 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102504_1 CDM 307 RC 81025 HCPCS outpatient 79 59.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 71.1 90 999999999 61.62 75.05 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102504_1 CDM 307 RC 81025 HCPCS outpatient 79 59.25 AETNA MCR ADV AETNA MCR ADV 61.62 78 999999999 61.62 75.05 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102504_1 CDM 307 RC 81025 HCPCS outpatient 79 59.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 69.18 87.57 999999999 61.62 75.05 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102504_1 CDM 307 RC 81025 HCPCS outpatient 79 59.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 67.21 85.07 999999999 61.62 75.05 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102504_1 CDM 307 RC 81025 HCPCS outpatient 79 59.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 67.21 85.07 999999999 61.62 75.05 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102504_1 CDM 307 RC 81025 HCPCS outpatient 79 59.25 MOLINA MCAID MOLINA MCAID 65.89 83.4 999999999 61.62 75.05 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102504_1 CDM 307 RC 81025 HCPCS outpatient 79 59.25 MOLINA MCR ADV MOLINA MCR ADV 70.31 89 999999999 61.62 75.05 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102504_1 CDM 307 RC 81025 HCPCS outpatient 79 59.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 70.31 89 999999999 61.62 75.05 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102504_1 CDM 307 RC 81025 HCPCS outpatient 79 59.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 70.31 89 999999999 61.62 75.05 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102504_1 CDM 307 RC 81025 HCPCS outpatient 79 59.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 71.1 90 999999999 61.62 75.05 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102504_1 CDM 307 RC 81025 HCPCS outpatient 79 59.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 75.05 95 999999999 61.62 75.05 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102504_1 CDM 307 RC 81025 HCPCS outpatient 79 59.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 75.05 95 999999999 61.62 75.05 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102504_1 CDM 307 RC 81025 HCPCS outpatient 79 59.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 70.31 89 999999999 61.62 75.05 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102504_1 CDM 307 RC 81025 HCPCS outpatient 79 59.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 69.52 88 999999999 61.62 75.05 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 3078102504_1 CDM 307 RC 81025 HCPCS outpatient 79 59.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 70.31 89 999999999 61.62 75.05 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_1 CDM 360 RC 30901 HCPCS outpatient 168.87 126.65 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 151.98 999999999 131.72 160.43 case rate "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_1 CDM 360 RC 30901 HCPCS outpatient 168.87 126.65 AETNA MCR ADV AETNA MCR ADV 131.72 78 999999999 131.72 160.43 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_1 CDM 360 RC 30901 HCPCS outpatient 168.87 126.65 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 147.88 87.57 999999999 131.72 160.43 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_1 CDM 360 RC 30901 HCPCS outpatient 168.87 126.65 COORDINATED CARE MCAID COORDINATED CARE MCAID 143.66 85.07 999999999 131.72 160.43 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_1 CDM 360 RC 30901 HCPCS outpatient 168.87 126.65 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 143.66 85.07 999999999 131.72 160.43 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_1 CDM 360 RC 30901 HCPCS outpatient 168.87 126.65 MOLINA MCAID MOLINA MCAID 140.84 83.4 999999999 131.72 160.43 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_1 CDM 360 RC 30901 HCPCS outpatient 168.87 126.65 MOLINA MCR ADV MOLINA MCR ADV 150.29 89 999999999 131.72 160.43 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_1 CDM 360 RC 30901 HCPCS outpatient 168.87 126.65 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 150.29 89 999999999 131.72 160.43 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_1 CDM 360 RC 30901 HCPCS outpatient 168.87 126.65 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 150.29 89 999999999 131.72 160.43 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_1 CDM 360 RC 30901 HCPCS outpatient 168.87 126.65 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 151.98 90 999999999 131.72 160.43 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_1 CDM 360 RC 30901 HCPCS outpatient 168.87 126.65 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 160.43 95 999999999 131.72 160.43 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_1 CDM 360 RC 30901 HCPCS outpatient 168.87 126.65 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 160.43 95 999999999 131.72 160.43 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_1 CDM 360 RC 30901 HCPCS outpatient 168.87 126.65 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 150.29 89 999999999 131.72 160.43 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_1 CDM 360 RC 30901 HCPCS outpatient 168.87 126.65 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 148.61 88 999999999 131.72 160.43 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_1 CDM 360 RC 30901 HCPCS outpatient 168.87 126.65 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 150.29 89 999999999 131.72 160.43 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_2 CDM 360 RC 30901 HCPCS outpatient 168.87 126.65 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 151.98 999999999 131.72 160.43 case rate "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_2 CDM 360 RC 30901 HCPCS outpatient 168.87 126.65 AETNA MCR ADV AETNA MCR ADV 131.72 78 999999999 131.72 160.43 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_2 CDM 360 RC 30901 HCPCS outpatient 168.87 126.65 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 147.88 87.57 999999999 131.72 160.43 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_2 CDM 360 RC 30901 HCPCS outpatient 168.87 126.65 COORDINATED CARE MCAID COORDINATED CARE MCAID 143.66 85.07 999999999 131.72 160.43 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_2 CDM 360 RC 30901 HCPCS outpatient 168.87 126.65 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 143.66 85.07 999999999 131.72 160.43 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_2 CDM 360 RC 30901 HCPCS outpatient 168.87 126.65 MOLINA MCAID MOLINA MCAID 140.84 83.4 999999999 131.72 160.43 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_2 CDM 360 RC 30901 HCPCS outpatient 168.87 126.65 MOLINA MCR ADV MOLINA MCR ADV 150.29 89 999999999 131.72 160.43 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_2 CDM 360 RC 30901 HCPCS outpatient 168.87 126.65 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 150.29 89 999999999 131.72 160.43 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_2 CDM 360 RC 30901 HCPCS outpatient 168.87 126.65 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 150.29 89 999999999 131.72 160.43 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_2 CDM 360 RC 30901 HCPCS outpatient 168.87 126.65 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 151.98 90 999999999 131.72 160.43 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_2 CDM 360 RC 30901 HCPCS outpatient 168.87 126.65 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 160.43 95 999999999 131.72 160.43 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_2 CDM 360 RC 30901 HCPCS outpatient 168.87 126.65 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 160.43 95 999999999 131.72 160.43 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_2 CDM 360 RC 30901 HCPCS outpatient 168.87 126.65 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 150.29 89 999999999 131.72 160.43 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_2 CDM 360 RC 30901 HCPCS outpatient 168.87 126.65 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 148.61 88 999999999 131.72 160.43 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_2 CDM 360 RC 30901 HCPCS outpatient 168.87 126.65 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 150.29 89 999999999 131.72 160.43 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_3 CDM 360 RC 30901 HCPCS outpatient 328 246 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 295.2 999999999 255.84 311.6 case rate "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_3 CDM 360 RC 30901 HCPCS outpatient 328 246 AETNA MCR ADV AETNA MCR ADV 255.84 78 999999999 255.84 311.6 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_3 CDM 360 RC 30901 HCPCS outpatient 328 246 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 287.23 87.57 999999999 255.84 311.6 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_3 CDM 360 RC 30901 HCPCS outpatient 328 246 COORDINATED CARE MCAID COORDINATED CARE MCAID 279.03 85.07 999999999 255.84 311.6 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_3 CDM 360 RC 30901 HCPCS outpatient 328 246 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 279.03 85.07 999999999 255.84 311.6 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_3 CDM 360 RC 30901 HCPCS outpatient 328 246 MOLINA MCAID MOLINA MCAID 273.55 83.4 999999999 255.84 311.6 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_3 CDM 360 RC 30901 HCPCS outpatient 328 246 MOLINA MCR ADV MOLINA MCR ADV 291.92 89 999999999 255.84 311.6 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_3 CDM 360 RC 30901 HCPCS outpatient 328 246 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 291.92 89 999999999 255.84 311.6 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_3 CDM 360 RC 30901 HCPCS outpatient 328 246 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 291.92 89 999999999 255.84 311.6 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_3 CDM 360 RC 30901 HCPCS outpatient 328 246 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 295.2 90 999999999 255.84 311.6 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_3 CDM 360 RC 30901 HCPCS outpatient 328 246 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 311.6 95 999999999 255.84 311.6 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_3 CDM 360 RC 30901 HCPCS outpatient 328 246 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 311.6 95 999999999 255.84 311.6 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_3 CDM 360 RC 30901 HCPCS outpatient 328 246 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 291.92 89 999999999 255.84 311.6 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_3 CDM 360 RC 30901 HCPCS outpatient 328 246 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 288.64 88 999999999 255.84 311.6 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 30901_3 CDM 360 RC 30901 HCPCS outpatient 328 246 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 291.92 89 999999999 255.84 311.6 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_1 CDM 360 RC 30903 HCPCS outpatient 229.71 172.28 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 206.74 999999999 179.17 218.22 case rate "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_1 CDM 360 RC 30903 HCPCS outpatient 229.71 172.28 AETNA MCR ADV AETNA MCR ADV 179.17 78 999999999 179.17 218.22 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_1 CDM 360 RC 30903 HCPCS outpatient 229.71 172.28 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 201.16 87.57 999999999 179.17 218.22 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_1 CDM 360 RC 30903 HCPCS outpatient 229.71 172.28 COORDINATED CARE MCAID COORDINATED CARE MCAID 195.41 85.07 999999999 179.17 218.22 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_1 CDM 360 RC 30903 HCPCS outpatient 229.71 172.28 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 195.41 85.07 999999999 179.17 218.22 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_1 CDM 360 RC 30903 HCPCS outpatient 229.71 172.28 MOLINA MCAID MOLINA MCAID 191.58 83.4 999999999 179.17 218.22 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_1 CDM 360 RC 30903 HCPCS outpatient 229.71 172.28 MOLINA MCR ADV MOLINA MCR ADV 204.44 89 999999999 179.17 218.22 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_1 CDM 360 RC 30903 HCPCS outpatient 229.71 172.28 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 204.44 89 999999999 179.17 218.22 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_1 CDM 360 RC 30903 HCPCS outpatient 229.71 172.28 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 204.44 89 999999999 179.17 218.22 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_1 CDM 360 RC 30903 HCPCS outpatient 229.71 172.28 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 206.74 90 999999999 179.17 218.22 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_1 CDM 360 RC 30903 HCPCS outpatient 229.71 172.28 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 218.22 95 999999999 179.17 218.22 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_1 CDM 360 RC 30903 HCPCS outpatient 229.71 172.28 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 218.22 95 999999999 179.17 218.22 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_1 CDM 360 RC 30903 HCPCS outpatient 229.71 172.28 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 204.44 89 999999999 179.17 218.22 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_1 CDM 360 RC 30903 HCPCS outpatient 229.71 172.28 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 202.14 88 999999999 179.17 218.22 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_1 CDM 360 RC 30903 HCPCS outpatient 229.71 172.28 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 204.44 89 999999999 179.17 218.22 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_2 CDM 360 RC 30903 HCPCS outpatient 229.71 172.28 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 206.74 999999999 179.17 218.22 case rate "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_2 CDM 360 RC 30903 HCPCS outpatient 229.71 172.28 AETNA MCR ADV AETNA MCR ADV 179.17 78 999999999 179.17 218.22 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_2 CDM 360 RC 30903 HCPCS outpatient 229.71 172.28 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 201.16 87.57 999999999 179.17 218.22 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_2 CDM 360 RC 30903 HCPCS outpatient 229.71 172.28 COORDINATED CARE MCAID COORDINATED CARE MCAID 195.41 85.07 999999999 179.17 218.22 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_2 CDM 360 RC 30903 HCPCS outpatient 229.71 172.28 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 195.41 85.07 999999999 179.17 218.22 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_2 CDM 360 RC 30903 HCPCS outpatient 229.71 172.28 MOLINA MCAID MOLINA MCAID 191.58 83.4 999999999 179.17 218.22 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_2 CDM 360 RC 30903 HCPCS outpatient 229.71 172.28 MOLINA MCR ADV MOLINA MCR ADV 204.44 89 999999999 179.17 218.22 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_2 CDM 360 RC 30903 HCPCS outpatient 229.71 172.28 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 204.44 89 999999999 179.17 218.22 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_2 CDM 360 RC 30903 HCPCS outpatient 229.71 172.28 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 204.44 89 999999999 179.17 218.22 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_2 CDM 360 RC 30903 HCPCS outpatient 229.71 172.28 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 206.74 90 999999999 179.17 218.22 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_2 CDM 360 RC 30903 HCPCS outpatient 229.71 172.28 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 218.22 95 999999999 179.17 218.22 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_2 CDM 360 RC 30903 HCPCS outpatient 229.71 172.28 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 218.22 95 999999999 179.17 218.22 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_2 CDM 360 RC 30903 HCPCS outpatient 229.71 172.28 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 204.44 89 999999999 179.17 218.22 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_2 CDM 360 RC 30903 HCPCS outpatient 229.71 172.28 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 202.14 88 999999999 179.17 218.22 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_2 CDM 360 RC 30903 HCPCS outpatient 229.71 172.28 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 204.44 89 999999999 179.17 218.22 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_3 CDM 360 RC 30903 HCPCS outpatient 516 387 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 464.4 999999999 402.48 490.2 case rate "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_3 CDM 360 RC 30903 HCPCS outpatient 516 387 AETNA MCR ADV AETNA MCR ADV 402.48 78 999999999 402.48 490.2 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_3 CDM 360 RC 30903 HCPCS outpatient 516 387 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 451.86 87.57 999999999 402.48 490.2 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_3 CDM 360 RC 30903 HCPCS outpatient 516 387 COORDINATED CARE MCAID COORDINATED CARE MCAID 438.96 85.07 999999999 402.48 490.2 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_3 CDM 360 RC 30903 HCPCS outpatient 516 387 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 438.96 85.07 999999999 402.48 490.2 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_3 CDM 360 RC 30903 HCPCS outpatient 516 387 MOLINA MCAID MOLINA MCAID 430.34 83.4 999999999 402.48 490.2 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_3 CDM 360 RC 30903 HCPCS outpatient 516 387 MOLINA MCR ADV MOLINA MCR ADV 459.24 89 999999999 402.48 490.2 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_3 CDM 360 RC 30903 HCPCS outpatient 516 387 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 459.24 89 999999999 402.48 490.2 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_3 CDM 360 RC 30903 HCPCS outpatient 516 387 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 459.24 89 999999999 402.48 490.2 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_3 CDM 360 RC 30903 HCPCS outpatient 516 387 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 464.4 90 999999999 402.48 490.2 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_3 CDM 360 RC 30903 HCPCS outpatient 516 387 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 490.2 95 999999999 402.48 490.2 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_3 CDM 360 RC 30903 HCPCS outpatient 516 387 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 490.2 95 999999999 402.48 490.2 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_3 CDM 360 RC 30903 HCPCS outpatient 516 387 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 459.24 89 999999999 402.48 490.2 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_3 CDM 360 RC 30903 HCPCS outpatient 516 387 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 454.08 88 999999999 402.48 490.2 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 30903_3 CDM 360 RC 30903 HCPCS outpatient 516 387 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 459.24 89 999999999 402.48 490.2 percent of total billed charges TAPENTADOL 3098037201_1 CDM 309 RC 80372 HCPCS outpatient 33 24.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 29.7 90 999999999 25.74 31.35 percent of total billed charges TAPENTADOL 3098037201_1 CDM 309 RC 80372 HCPCS outpatient 33 24.75 AETNA MCR ADV AETNA MCR ADV 25.74 78 999999999 25.74 31.35 percent of total billed charges TAPENTADOL 3098037201_1 CDM 309 RC 80372 HCPCS outpatient 33 24.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 28.9 87.57 999999999 25.74 31.35 percent of total billed charges TAPENTADOL 3098037201_1 CDM 309 RC 80372 HCPCS outpatient 33 24.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 28.07 85.07 999999999 25.74 31.35 percent of total billed charges TAPENTADOL 3098037201_1 CDM 309 RC 80372 HCPCS outpatient 33 24.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 28.07 85.07 999999999 25.74 31.35 percent of total billed charges TAPENTADOL 3098037201_1 CDM 309 RC 80372 HCPCS outpatient 33 24.75 MOLINA MCAID MOLINA MCAID 27.52 83.4 999999999 25.74 31.35 percent of total billed charges TAPENTADOL 3098037201_1 CDM 309 RC 80372 HCPCS outpatient 33 24.75 MOLINA MCR ADV MOLINA MCR ADV 29.37 89 999999999 25.74 31.35 percent of total billed charges TAPENTADOL 3098037201_1 CDM 309 RC 80372 HCPCS outpatient 33 24.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 29.37 89 999999999 25.74 31.35 percent of total billed charges TAPENTADOL 3098037201_1 CDM 309 RC 80372 HCPCS outpatient 33 24.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 29.37 89 999999999 25.74 31.35 percent of total billed charges TAPENTADOL 3098037201_1 CDM 309 RC 80372 HCPCS outpatient 33 24.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 29.7 90 999999999 25.74 31.35 percent of total billed charges TAPENTADOL 3098037201_1 CDM 309 RC 80372 HCPCS outpatient 33 24.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 31.35 95 999999999 25.74 31.35 percent of total billed charges TAPENTADOL 3098037201_1 CDM 309 RC 80372 HCPCS outpatient 33 24.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 31.35 95 999999999 25.74 31.35 percent of total billed charges TAPENTADOL 3098037201_1 CDM 309 RC 80372 HCPCS outpatient 33 24.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 29.37 89 999999999 25.74 31.35 percent of total billed charges TAPENTADOL 3098037201_1 CDM 309 RC 80372 HCPCS outpatient 33 24.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 29.04 88 999999999 25.74 31.35 percent of total billed charges TAPENTADOL 3098037201_1 CDM 309 RC 80372 HCPCS outpatient 33 24.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 29.37 89 999999999 25.74 31.35 percent of total billed charges "FAT STAIN, FECES, URINE, OR RESPIRATORY SECRETIONS" 3098912501_1 CDM 309 RC 89125 HCPCS outpatient 61 45.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 54.9 90 999999999 47.58 57.95 percent of total billed charges "FAT STAIN, FECES, URINE, OR RESPIRATORY SECRETIONS" 3098912501_1 CDM 309 RC 89125 HCPCS outpatient 61 45.75 AETNA MCR ADV AETNA MCR ADV 47.58 78 999999999 47.58 57.95 percent of total billed charges "FAT STAIN, FECES, URINE, OR RESPIRATORY SECRETIONS" 3098912501_1 CDM 309 RC 89125 HCPCS outpatient 61 45.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 53.42 87.57 999999999 47.58 57.95 percent of total billed charges "FAT STAIN, FECES, URINE, OR RESPIRATORY SECRETIONS" 3098912501_1 CDM 309 RC 89125 HCPCS outpatient 61 45.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 51.89 85.07 999999999 47.58 57.95 percent of total billed charges "FAT STAIN, FECES, URINE, OR RESPIRATORY SECRETIONS" 3098912501_1 CDM 309 RC 89125 HCPCS outpatient 61 45.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 51.89 85.07 999999999 47.58 57.95 percent of total billed charges "FAT STAIN, FECES, URINE, OR RESPIRATORY SECRETIONS" 3098912501_1 CDM 309 RC 89125 HCPCS outpatient 61 45.75 MOLINA MCAID MOLINA MCAID 50.87 83.4 999999999 47.58 57.95 percent of total billed charges "FAT STAIN, FECES, URINE, OR RESPIRATORY SECRETIONS" 3098912501_1 CDM 309 RC 89125 HCPCS outpatient 61 45.75 MOLINA MCR ADV MOLINA MCR ADV 54.29 89 999999999 47.58 57.95 percent of total billed charges "FAT STAIN, FECES, URINE, OR RESPIRATORY SECRETIONS" 3098912501_1 CDM 309 RC 89125 HCPCS outpatient 61 45.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 54.29 89 999999999 47.58 57.95 percent of total billed charges "FAT STAIN, FECES, URINE, OR RESPIRATORY SECRETIONS" 3098912501_1 CDM 309 RC 89125 HCPCS outpatient 61 45.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 54.29 89 999999999 47.58 57.95 percent of total billed charges "FAT STAIN, FECES, URINE, OR RESPIRATORY SECRETIONS" 3098912501_1 CDM 309 RC 89125 HCPCS outpatient 61 45.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 54.9 90 999999999 47.58 57.95 percent of total billed charges "FAT STAIN, FECES, URINE, OR RESPIRATORY SECRETIONS" 3098912501_1 CDM 309 RC 89125 HCPCS outpatient 61 45.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 57.95 95 999999999 47.58 57.95 percent of total billed charges "FAT STAIN, FECES, URINE, OR RESPIRATORY SECRETIONS" 3098912501_1 CDM 309 RC 89125 HCPCS outpatient 61 45.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 57.95 95 999999999 47.58 57.95 percent of total billed charges "FAT STAIN, FECES, URINE, OR RESPIRATORY SECRETIONS" 3098912501_1 CDM 309 RC 89125 HCPCS outpatient 61 45.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 54.29 89 999999999 47.58 57.95 percent of total billed charges "FAT STAIN, FECES, URINE, OR RESPIRATORY SECRETIONS" 3098912501_1 CDM 309 RC 89125 HCPCS outpatient 61 45.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 53.68 88 999999999 47.58 57.95 percent of total billed charges "FAT STAIN, FECES, URINE, OR RESPIRATORY SECRETIONS" 3098912501_1 CDM 309 RC 89125 HCPCS outpatient 61 45.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 54.29 89 999999999 47.58 57.95 percent of total billed charges "SEMEN ANALYSIS; VOLUME, COUNT, MOTILITY, AND DIFFERENTIAL" 3098932001_1 CDM 309 RC 89320 HCPCS outpatient 127 95.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 114.3 90 999999999 99.06 120.65 percent of total billed charges "SEMEN ANALYSIS; VOLUME, COUNT, MOTILITY, AND DIFFERENTIAL" 3098932001_1 CDM 309 RC 89320 HCPCS outpatient 127 95.25 AETNA MCR ADV AETNA MCR ADV 99.06 78 999999999 99.06 120.65 percent of total billed charges "SEMEN ANALYSIS; VOLUME, COUNT, MOTILITY, AND DIFFERENTIAL" 3098932001_1 CDM 309 RC 89320 HCPCS outpatient 127 95.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 111.21 87.57 999999999 99.06 120.65 percent of total billed charges "SEMEN ANALYSIS; VOLUME, COUNT, MOTILITY, AND DIFFERENTIAL" 3098932001_1 CDM 309 RC 89320 HCPCS outpatient 127 95.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 108.04 85.07 999999999 99.06 120.65 percent of total billed charges "SEMEN ANALYSIS; VOLUME, COUNT, MOTILITY, AND DIFFERENTIAL" 3098932001_1 CDM 309 RC 89320 HCPCS outpatient 127 95.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 108.04 85.07 999999999 99.06 120.65 percent of total billed charges "SEMEN ANALYSIS; VOLUME, COUNT, MOTILITY, AND DIFFERENTIAL" 3098932001_1 CDM 309 RC 89320 HCPCS outpatient 127 95.25 MOLINA MCAID MOLINA MCAID 105.92 83.4 999999999 99.06 120.65 percent of total billed charges "SEMEN ANALYSIS; VOLUME, COUNT, MOTILITY, AND DIFFERENTIAL" 3098932001_1 CDM 309 RC 89320 HCPCS outpatient 127 95.25 MOLINA MCR ADV MOLINA MCR ADV 113.03 89 999999999 99.06 120.65 percent of total billed charges "SEMEN ANALYSIS; VOLUME, COUNT, MOTILITY, AND DIFFERENTIAL" 3098932001_1 CDM 309 RC 89320 HCPCS outpatient 127 95.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 113.03 89 999999999 99.06 120.65 percent of total billed charges "SEMEN ANALYSIS; VOLUME, COUNT, MOTILITY, AND DIFFERENTIAL" 3098932001_1 CDM 309 RC 89320 HCPCS outpatient 127 95.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 113.03 89 999999999 99.06 120.65 percent of total billed charges "SEMEN ANALYSIS; VOLUME, COUNT, MOTILITY, AND DIFFERENTIAL" 3098932001_1 CDM 309 RC 89320 HCPCS outpatient 127 95.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 114.3 90 999999999 99.06 120.65 percent of total billed charges "SEMEN ANALYSIS; VOLUME, COUNT, MOTILITY, AND DIFFERENTIAL" 3098932001_1 CDM 309 RC 89320 HCPCS outpatient 127 95.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 120.65 95 999999999 99.06 120.65 percent of total billed charges "SEMEN ANALYSIS; VOLUME, COUNT, MOTILITY, AND DIFFERENTIAL" 3098932001_1 CDM 309 RC 89320 HCPCS outpatient 127 95.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 120.65 95 999999999 99.06 120.65 percent of total billed charges "SEMEN ANALYSIS; VOLUME, COUNT, MOTILITY, AND DIFFERENTIAL" 3098932001_1 CDM 309 RC 89320 HCPCS outpatient 127 95.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 113.03 89 999999999 99.06 120.65 percent of total billed charges "SEMEN ANALYSIS; VOLUME, COUNT, MOTILITY, AND DIFFERENTIAL" 3098932001_1 CDM 309 RC 89320 HCPCS outpatient 127 95.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 111.76 88 999999999 99.06 120.65 percent of total billed charges "SEMEN ANALYSIS; VOLUME, COUNT, MOTILITY, AND DIFFERENTIAL" 3098932001_1 CDM 309 RC 89320 HCPCS outpatient 127 95.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 113.03 89 999999999 99.06 120.65 percent of total billed charges "FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC, OR NUCLEAR MARKER, TECHNICAL COMPONENT ONLY; FIRST MARKER" 3118818401_1 CDM 311 RC 88184 HCPCS outpatient 142 106.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 127.8 90 999999999 110.76 134.9 percent of total billed charges "FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC, OR NUCLEAR MARKER, TECHNICAL COMPONENT ONLY; FIRST MARKER" 3118818401_1 CDM 311 RC 88184 HCPCS outpatient 142 106.5 AETNA MCR ADV AETNA MCR ADV 110.76 78 999999999 110.76 134.9 percent of total billed charges "FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC, OR NUCLEAR MARKER, TECHNICAL COMPONENT ONLY; FIRST MARKER" 3118818401_1 CDM 311 RC 88184 HCPCS outpatient 142 106.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 124.35 87.57 999999999 110.76 134.9 percent of total billed charges "FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC, OR NUCLEAR MARKER, TECHNICAL COMPONENT ONLY; FIRST MARKER" 3118818401_1 CDM 311 RC 88184 HCPCS outpatient 142 106.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 120.8 85.07 999999999 110.76 134.9 percent of total billed charges "FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC, OR NUCLEAR MARKER, TECHNICAL COMPONENT ONLY; FIRST MARKER" 3118818401_1 CDM 311 RC 88184 HCPCS outpatient 142 106.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 120.8 85.07 999999999 110.76 134.9 percent of total billed charges "FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC, OR NUCLEAR MARKER, TECHNICAL COMPONENT ONLY; FIRST MARKER" 3118818401_1 CDM 311 RC 88184 HCPCS outpatient 142 106.5 MOLINA MCAID MOLINA MCAID 118.43 83.4 999999999 110.76 134.9 percent of total billed charges "FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC, OR NUCLEAR MARKER, TECHNICAL COMPONENT ONLY; FIRST MARKER" 3118818401_1 CDM 311 RC 88184 HCPCS outpatient 142 106.5 MOLINA MCR ADV MOLINA MCR ADV 126.38 89 999999999 110.76 134.9 percent of total billed charges "FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC, OR NUCLEAR MARKER, TECHNICAL COMPONENT ONLY; FIRST MARKER" 3118818401_1 CDM 311 RC 88184 HCPCS outpatient 142 106.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 126.38 89 999999999 110.76 134.9 percent of total billed charges "FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC, OR NUCLEAR MARKER, TECHNICAL COMPONENT ONLY; FIRST MARKER" 3118818401_1 CDM 311 RC 88184 HCPCS outpatient 142 106.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 126.38 89 999999999 110.76 134.9 percent of total billed charges "FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC, OR NUCLEAR MARKER, TECHNICAL COMPONENT ONLY; FIRST MARKER" 3118818401_1 CDM 311 RC 88184 HCPCS outpatient 142 106.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 127.8 90 999999999 110.76 134.9 percent of total billed charges "FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC, OR NUCLEAR MARKER, TECHNICAL COMPONENT ONLY; FIRST MARKER" 3118818401_1 CDM 311 RC 88184 HCPCS outpatient 142 106.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 134.9 95 999999999 110.76 134.9 percent of total billed charges "FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC, OR NUCLEAR MARKER, TECHNICAL COMPONENT ONLY; FIRST MARKER" 3118818401_1 CDM 311 RC 88184 HCPCS outpatient 142 106.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 134.9 95 999999999 110.76 134.9 percent of total billed charges "FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC, OR NUCLEAR MARKER, TECHNICAL COMPONENT ONLY; FIRST MARKER" 3118818401_1 CDM 311 RC 88184 HCPCS outpatient 142 106.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 126.38 89 999999999 110.76 134.9 percent of total billed charges "FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC, OR NUCLEAR MARKER, TECHNICAL COMPONENT ONLY; FIRST MARKER" 3118818401_1 CDM 311 RC 88184 HCPCS outpatient 142 106.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 124.96 88 999999999 110.76 134.9 percent of total billed charges "FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC, OR NUCLEAR MARKER, TECHNICAL COMPONENT ONLY; FIRST MARKER" 3118818401_1 CDM 311 RC 88184 HCPCS outpatient 142 106.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 126.38 89 999999999 110.76 134.9 percent of total billed charges "FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC, OR NUCLEAR MARKER, TECHNICAL COMPONENT ONLY; EACH ADDITIONAL MARKER (LIST SEPARATELY IN ADDITION TO CODE FOR FIRST MARKER)" 3118818501_1 CDM 311 RC 88185 HCPCS outpatient 98 73.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 88.2 90 999999999 76.44 93.1 percent of total billed charges "FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC, OR NUCLEAR MARKER, TECHNICAL COMPONENT ONLY; EACH ADDITIONAL MARKER (LIST SEPARATELY IN ADDITION TO CODE FOR FIRST MARKER)" 3118818501_1 CDM 311 RC 88185 HCPCS outpatient 98 73.5 AETNA MCR ADV AETNA MCR ADV 76.44 78 999999999 76.44 93.1 percent of total billed charges "FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC, OR NUCLEAR MARKER, TECHNICAL COMPONENT ONLY; EACH ADDITIONAL MARKER (LIST SEPARATELY IN ADDITION TO CODE FOR FIRST MARKER)" 3118818501_1 CDM 311 RC 88185 HCPCS outpatient 98 73.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 85.82 87.57 999999999 76.44 93.1 percent of total billed charges "FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC, OR NUCLEAR MARKER, TECHNICAL COMPONENT ONLY; EACH ADDITIONAL MARKER (LIST SEPARATELY IN ADDITION TO CODE FOR FIRST MARKER)" 3118818501_1 CDM 311 RC 88185 HCPCS outpatient 98 73.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 83.37 85.07 999999999 76.44 93.1 percent of total billed charges "FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC, OR NUCLEAR MARKER, TECHNICAL COMPONENT ONLY; EACH ADDITIONAL MARKER (LIST SEPARATELY IN ADDITION TO CODE FOR FIRST MARKER)" 3118818501_1 CDM 311 RC 88185 HCPCS outpatient 98 73.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 83.37 85.07 999999999 76.44 93.1 percent of total billed charges "FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC, OR NUCLEAR MARKER, TECHNICAL COMPONENT ONLY; EACH ADDITIONAL MARKER (LIST SEPARATELY IN ADDITION TO CODE FOR FIRST MARKER)" 3118818501_1 CDM 311 RC 88185 HCPCS outpatient 98 73.5 MOLINA MCAID MOLINA MCAID 81.73 83.4 999999999 76.44 93.1 percent of total billed charges "FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC, OR NUCLEAR MARKER, TECHNICAL COMPONENT ONLY; EACH ADDITIONAL MARKER (LIST SEPARATELY IN ADDITION TO CODE FOR FIRST MARKER)" 3118818501_1 CDM 311 RC 88185 HCPCS outpatient 98 73.5 MOLINA MCR ADV MOLINA MCR ADV 87.22 89 999999999 76.44 93.1 percent of total billed charges "FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC, OR NUCLEAR MARKER, TECHNICAL COMPONENT ONLY; EACH ADDITIONAL MARKER (LIST SEPARATELY IN ADDITION TO CODE FOR FIRST MARKER)" 3118818501_1 CDM 311 RC 88185 HCPCS outpatient 98 73.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 87.22 89 999999999 76.44 93.1 percent of total billed charges "FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC, OR NUCLEAR MARKER, TECHNICAL COMPONENT ONLY; EACH ADDITIONAL MARKER (LIST SEPARATELY IN ADDITION TO CODE FOR FIRST MARKER)" 3118818501_1 CDM 311 RC 88185 HCPCS outpatient 98 73.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 87.22 89 999999999 76.44 93.1 percent of total billed charges "FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC, OR NUCLEAR MARKER, TECHNICAL COMPONENT ONLY; EACH ADDITIONAL MARKER (LIST SEPARATELY IN ADDITION TO CODE FOR FIRST MARKER)" 3118818501_1 CDM 311 RC 88185 HCPCS outpatient 98 73.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 88.2 90 999999999 76.44 93.1 percent of total billed charges "FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC, OR NUCLEAR MARKER, TECHNICAL COMPONENT ONLY; EACH ADDITIONAL MARKER (LIST SEPARATELY IN ADDITION TO CODE FOR FIRST MARKER)" 3118818501_1 CDM 311 RC 88185 HCPCS outpatient 98 73.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 93.1 95 999999999 76.44 93.1 percent of total billed charges "FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC, OR NUCLEAR MARKER, TECHNICAL COMPONENT ONLY; EACH ADDITIONAL MARKER (LIST SEPARATELY IN ADDITION TO CODE FOR FIRST MARKER)" 3118818501_1 CDM 311 RC 88185 HCPCS outpatient 98 73.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 93.1 95 999999999 76.44 93.1 percent of total billed charges "FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC, OR NUCLEAR MARKER, TECHNICAL COMPONENT ONLY; EACH ADDITIONAL MARKER (LIST SEPARATELY IN ADDITION TO CODE FOR FIRST MARKER)" 3118818501_1 CDM 311 RC 88185 HCPCS outpatient 98 73.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 87.22 89 999999999 76.44 93.1 percent of total billed charges "FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC, OR NUCLEAR MARKER, TECHNICAL COMPONENT ONLY; EACH ADDITIONAL MARKER (LIST SEPARATELY IN ADDITION TO CODE FOR FIRST MARKER)" 3118818501_1 CDM 311 RC 88185 HCPCS outpatient 98 73.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 86.24 88 999999999 76.44 93.1 percent of total billed charges "FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC, OR NUCLEAR MARKER, TECHNICAL COMPONENT ONLY; EACH ADDITIONAL MARKER (LIST SEPARATELY IN ADDITION TO CODE FOR FIRST MARKER)" 3118818501_1 CDM 311 RC 88185 HCPCS outpatient 98 73.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 87.22 89 999999999 76.44 93.1 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 31500_1 CDM 360 RC 31500 HCPCS outpatient 420.75 315.56 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 378.68 999999999 328.19 399.71 case rate "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 31500_1 CDM 360 RC 31500 HCPCS outpatient 420.75 315.56 AETNA MCR ADV AETNA MCR ADV 328.19 78 999999999 328.19 399.71 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 31500_1 CDM 360 RC 31500 HCPCS outpatient 420.75 315.56 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 368.45 87.57 999999999 328.19 399.71 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 31500_1 CDM 360 RC 31500 HCPCS outpatient 420.75 315.56 COORDINATED CARE MCAID COORDINATED CARE MCAID 357.93 85.07 999999999 328.19 399.71 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 31500_1 CDM 360 RC 31500 HCPCS outpatient 420.75 315.56 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 357.93 85.07 999999999 328.19 399.71 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 31500_1 CDM 360 RC 31500 HCPCS outpatient 420.75 315.56 MOLINA MCAID MOLINA MCAID 350.91 83.4 999999999 328.19 399.71 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 31500_1 CDM 360 RC 31500 HCPCS outpatient 420.75 315.56 MOLINA MCR ADV MOLINA MCR ADV 374.47 89 999999999 328.19 399.71 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 31500_1 CDM 360 RC 31500 HCPCS outpatient 420.75 315.56 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 374.47 89 999999999 328.19 399.71 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 31500_1 CDM 360 RC 31500 HCPCS outpatient 420.75 315.56 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 374.47 89 999999999 328.19 399.71 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 31500_1 CDM 360 RC 31500 HCPCS outpatient 420.75 315.56 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 378.68 90 999999999 328.19 399.71 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 31500_1 CDM 360 RC 31500 HCPCS outpatient 420.75 315.56 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 399.71 95 999999999 328.19 399.71 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 31500_1 CDM 360 RC 31500 HCPCS outpatient 420.75 315.56 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 399.71 95 999999999 328.19 399.71 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 31500_1 CDM 360 RC 31500 HCPCS outpatient 420.75 315.56 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 374.47 89 999999999 328.19 399.71 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 31500_1 CDM 360 RC 31500 HCPCS outpatient 420.75 315.56 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 370.26 88 999999999 328.19 399.71 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 31500_1 CDM 360 RC 31500 HCPCS outpatient 420.75 315.56 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 374.47 89 999999999 328.19 399.71 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 31500_2 CDM 360 RC 31500 HCPCS outpatient 420.75 315.56 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 378.68 999999999 328.19 399.71 case rate "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 31500_2 CDM 360 RC 31500 HCPCS outpatient 420.75 315.56 AETNA MCR ADV AETNA MCR ADV 328.19 78 999999999 328.19 399.71 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 31500_2 CDM 360 RC 31500 HCPCS outpatient 420.75 315.56 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 368.45 87.57 999999999 328.19 399.71 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 31500_2 CDM 360 RC 31500 HCPCS outpatient 420.75 315.56 COORDINATED CARE MCAID COORDINATED CARE MCAID 357.93 85.07 999999999 328.19 399.71 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 31500_2 CDM 360 RC 31500 HCPCS outpatient 420.75 315.56 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 357.93 85.07 999999999 328.19 399.71 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 31500_2 CDM 360 RC 31500 HCPCS outpatient 420.75 315.56 MOLINA MCAID MOLINA MCAID 350.91 83.4 999999999 328.19 399.71 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 31500_2 CDM 360 RC 31500 HCPCS outpatient 420.75 315.56 MOLINA MCR ADV MOLINA MCR ADV 374.47 89 999999999 328.19 399.71 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 31500_2 CDM 360 RC 31500 HCPCS outpatient 420.75 315.56 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 374.47 89 999999999 328.19 399.71 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 31500_2 CDM 360 RC 31500 HCPCS outpatient 420.75 315.56 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 374.47 89 999999999 328.19 399.71 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 31500_2 CDM 360 RC 31500 HCPCS outpatient 420.75 315.56 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 378.68 90 999999999 328.19 399.71 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 31500_2 CDM 360 RC 31500 HCPCS outpatient 420.75 315.56 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 399.71 95 999999999 328.19 399.71 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 31500_2 CDM 360 RC 31500 HCPCS outpatient 420.75 315.56 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 399.71 95 999999999 328.19 399.71 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 31500_2 CDM 360 RC 31500 HCPCS outpatient 420.75 315.56 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 374.47 89 999999999 328.19 399.71 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 31500_2 CDM 360 RC 31500 HCPCS outpatient 420.75 315.56 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 370.26 88 999999999 328.19 399.71 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 31500_2 CDM 360 RC 31500 HCPCS outpatient 420.75 315.56 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 374.47 89 999999999 328.19 399.71 percent of total billed charges "LARYNGOSCOPY, INDIRECT; DIAGNOSTIC (SEPARATE PROCEDURE)" 31505_1 CDM 360 RC 31505 HCPCS outpatient 148.17 111.13 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 133.35 999999999 115.57 140.76 case rate "LARYNGOSCOPY, INDIRECT; DIAGNOSTIC (SEPARATE PROCEDURE)" 31505_1 CDM 360 RC 31505 HCPCS outpatient 148.17 111.13 AETNA MCR ADV AETNA MCR ADV 115.57 78 999999999 115.57 140.76 percent of total billed charges "LARYNGOSCOPY, INDIRECT; DIAGNOSTIC (SEPARATE PROCEDURE)" 31505_1 CDM 360 RC 31505 HCPCS outpatient 148.17 111.13 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 129.75 87.57 999999999 115.57 140.76 percent of total billed charges "LARYNGOSCOPY, INDIRECT; DIAGNOSTIC (SEPARATE PROCEDURE)" 31505_1 CDM 360 RC 31505 HCPCS outpatient 148.17 111.13 COORDINATED CARE MCAID COORDINATED CARE MCAID 126.05 85.07 999999999 115.57 140.76 percent of total billed charges "LARYNGOSCOPY, INDIRECT; DIAGNOSTIC (SEPARATE PROCEDURE)" 31505_1 CDM 360 RC 31505 HCPCS outpatient 148.17 111.13 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 126.05 85.07 999999999 115.57 140.76 percent of total billed charges "LARYNGOSCOPY, INDIRECT; DIAGNOSTIC (SEPARATE PROCEDURE)" 31505_1 CDM 360 RC 31505 HCPCS outpatient 148.17 111.13 MOLINA MCAID MOLINA MCAID 123.57 83.4 999999999 115.57 140.76 percent of total billed charges "LARYNGOSCOPY, INDIRECT; DIAGNOSTIC (SEPARATE PROCEDURE)" 31505_1 CDM 360 RC 31505 HCPCS outpatient 148.17 111.13 MOLINA MCR ADV MOLINA MCR ADV 131.87 89 999999999 115.57 140.76 percent of total billed charges "LARYNGOSCOPY, INDIRECT; DIAGNOSTIC (SEPARATE PROCEDURE)" 31505_1 CDM 360 RC 31505 HCPCS outpatient 148.17 111.13 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 131.87 89 999999999 115.57 140.76 percent of total billed charges "LARYNGOSCOPY, INDIRECT; DIAGNOSTIC (SEPARATE PROCEDURE)" 31505_1 CDM 360 RC 31505 HCPCS outpatient 148.17 111.13 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 131.87 89 999999999 115.57 140.76 percent of total billed charges "LARYNGOSCOPY, INDIRECT; DIAGNOSTIC (SEPARATE PROCEDURE)" 31505_1 CDM 360 RC 31505 HCPCS outpatient 148.17 111.13 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 133.35 90 999999999 115.57 140.76 percent of total billed charges "LARYNGOSCOPY, INDIRECT; DIAGNOSTIC (SEPARATE PROCEDURE)" 31505_1 CDM 360 RC 31505 HCPCS outpatient 148.17 111.13 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 140.76 95 999999999 115.57 140.76 percent of total billed charges "LARYNGOSCOPY, INDIRECT; DIAGNOSTIC (SEPARATE PROCEDURE)" 31505_1 CDM 360 RC 31505 HCPCS outpatient 148.17 111.13 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 140.76 95 999999999 115.57 140.76 percent of total billed charges "LARYNGOSCOPY, INDIRECT; DIAGNOSTIC (SEPARATE PROCEDURE)" 31505_1 CDM 360 RC 31505 HCPCS outpatient 148.17 111.13 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 131.87 89 999999999 115.57 140.76 percent of total billed charges "LARYNGOSCOPY, INDIRECT; DIAGNOSTIC (SEPARATE PROCEDURE)" 31505_1 CDM 360 RC 31505 HCPCS outpatient 148.17 111.13 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 130.39 88 999999999 115.57 140.76 percent of total billed charges "LARYNGOSCOPY, INDIRECT; DIAGNOSTIC (SEPARATE PROCEDURE)" 31505_1 CDM 360 RC 31505 HCPCS outpatient 148.17 111.13 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 131.87 89 999999999 115.57 140.76 percent of total billed charges "THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE" 32554_1 CDM 960 RC 32554 HCPCS outpatient 267.57 200.68 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 349.88 999999999 119.28 349.88 fee schedule "THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE" 32554_1 CDM 960 RC 32554 HCPCS outpatient 267.57 200.68 AETNA MCR ADV AETNA MCR ADV 267.57 999999999 119.28 349.88 fee schedule "THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE" 32554_1 CDM 960 RC 32554 HCPCS outpatient 267.57 200.68 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 144.52 999999999 119.28 349.88 fee schedule "THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE" 32554_1 CDM 960 RC 32554 HCPCS outpatient 267.57 200.68 COORDINATED CARE MCAID COORDINATED CARE MCAID 137.64 999999999 119.28 349.88 fee schedule "THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE" 32554_1 CDM 960 RC 32554 HCPCS outpatient 267.57 200.68 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 267.57 999999999 119.28 349.88 fee schedule "THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE" 32554_1 CDM 960 RC 32554 HCPCS outpatient 267.57 200.68 MOLINA MCAID MOLINA MCAID 144.52 999999999 119.28 349.88 fee schedule "THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE" 32554_1 CDM 960 RC 32554 HCPCS outpatient 267.57 200.68 MOLINA MCR ADV MOLINA MCR ADV 267.57 999999999 119.28 349.88 fee schedule "THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE" 32554_1 CDM 960 RC 32554 HCPCS outpatient 267.57 200.68 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 267.57 999999999 119.28 349.88 fee schedule "THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE" 32554_1 CDM 960 RC 32554 HCPCS outpatient 267.57 200.68 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 267.57 999999999 119.28 349.88 fee schedule "THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE" 32554_1 CDM 960 RC 32554 HCPCS outpatient 267.57 200.68 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 273.59 999999999 119.28 349.88 fee schedule "THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE" 32554_1 CDM 960 RC 32554 HCPCS outpatient 267.57 200.68 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 129.5 999999999 119.28 349.88 fee schedule "THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE" 32554_1 CDM 960 RC 32554 HCPCS outpatient 267.57 200.68 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 129.5 999999999 119.28 349.88 fee schedule "THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE" 32554_1 CDM 960 RC 32554 HCPCS outpatient 267.57 200.68 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 267.57 999999999 119.28 349.88 fee schedule "THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE" 32554_1 CDM 960 RC 32554 HCPCS outpatient 267.57 200.68 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 119.28 999999999 119.28 349.88 fee schedule "THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE" 32554_1 CDM 960 RC 32554 HCPCS outpatient 267.57 200.68 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 267.57 999999999 119.28 349.88 fee schedule "COMPUTED TOMOGRAPHY, THORAX, LOW DOSE FOR LUNG CANCER SCREENING, WITHOUT CONTRAST MATERIAL(S)" 3507127101_1 CDM 350 RC 71271 HCPCS outpatient 1071 803.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 963.9 90 999999999 835.38 1017.45 percent of total billed charges "COMPUTED TOMOGRAPHY, THORAX, LOW DOSE FOR LUNG CANCER SCREENING, WITHOUT CONTRAST MATERIAL(S)" 3507127101_1 CDM 350 RC 71271 HCPCS outpatient 1071 803.25 AETNA MCR ADV AETNA MCR ADV 835.38 78 999999999 835.38 1017.45 percent of total billed charges "COMPUTED TOMOGRAPHY, THORAX, LOW DOSE FOR LUNG CANCER SCREENING, WITHOUT CONTRAST MATERIAL(S)" 3507127101_1 CDM 350 RC 71271 HCPCS outpatient 1071 803.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 937.87 87.57 999999999 835.38 1017.45 percent of total billed charges "COMPUTED TOMOGRAPHY, THORAX, LOW DOSE FOR LUNG CANCER SCREENING, WITHOUT CONTRAST MATERIAL(S)" 3507127101_1 CDM 350 RC 71271 HCPCS outpatient 1071 803.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 911.1 85.07 999999999 835.38 1017.45 percent of total billed charges "COMPUTED TOMOGRAPHY, THORAX, LOW DOSE FOR LUNG CANCER SCREENING, WITHOUT CONTRAST MATERIAL(S)" 3507127101_1 CDM 350 RC 71271 HCPCS outpatient 1071 803.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 911.1 85.07 999999999 835.38 1017.45 percent of total billed charges "COMPUTED TOMOGRAPHY, THORAX, LOW DOSE FOR LUNG CANCER SCREENING, WITHOUT CONTRAST MATERIAL(S)" 3507127101_1 CDM 350 RC 71271 HCPCS outpatient 1071 803.25 MOLINA MCAID MOLINA MCAID 893.21 83.4 999999999 835.38 1017.45 percent of total billed charges "COMPUTED TOMOGRAPHY, THORAX, LOW DOSE FOR LUNG CANCER SCREENING, WITHOUT CONTRAST MATERIAL(S)" 3507127101_1 CDM 350 RC 71271 HCPCS outpatient 1071 803.25 MOLINA MCR ADV MOLINA MCR ADV 953.19 89 999999999 835.38 1017.45 percent of total billed charges "COMPUTED TOMOGRAPHY, THORAX, LOW DOSE FOR LUNG CANCER SCREENING, WITHOUT CONTRAST MATERIAL(S)" 3507127101_1 CDM 350 RC 71271 HCPCS outpatient 1071 803.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 953.19 89 999999999 835.38 1017.45 percent of total billed charges "COMPUTED TOMOGRAPHY, THORAX, LOW DOSE FOR LUNG CANCER SCREENING, WITHOUT CONTRAST MATERIAL(S)" 3507127101_1 CDM 350 RC 71271 HCPCS outpatient 1071 803.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 953.19 89 999999999 835.38 1017.45 percent of total billed charges "COMPUTED TOMOGRAPHY, THORAX, LOW DOSE FOR LUNG CANCER SCREENING, WITHOUT CONTRAST MATERIAL(S)" 3507127101_1 CDM 350 RC 71271 HCPCS outpatient 1071 803.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 963.9 90 999999999 835.38 1017.45 percent of total billed charges "COMPUTED TOMOGRAPHY, THORAX, LOW DOSE FOR LUNG CANCER SCREENING, WITHOUT CONTRAST MATERIAL(S)" 3507127101_1 CDM 350 RC 71271 HCPCS outpatient 1071 803.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1017.45 95 999999999 835.38 1017.45 percent of total billed charges "COMPUTED TOMOGRAPHY, THORAX, LOW DOSE FOR LUNG CANCER SCREENING, WITHOUT CONTRAST MATERIAL(S)" 3507127101_1 CDM 350 RC 71271 HCPCS outpatient 1071 803.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1017.45 95 999999999 835.38 1017.45 percent of total billed charges "COMPUTED TOMOGRAPHY, THORAX, LOW DOSE FOR LUNG CANCER SCREENING, WITHOUT CONTRAST MATERIAL(S)" 3507127101_1 CDM 350 RC 71271 HCPCS outpatient 1071 803.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 953.19 89 999999999 835.38 1017.45 percent of total billed charges "COMPUTED TOMOGRAPHY, THORAX, LOW DOSE FOR LUNG CANCER SCREENING, WITHOUT CONTRAST MATERIAL(S)" 3507127101_1 CDM 350 RC 71271 HCPCS outpatient 1071 803.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 942.48 88 999999999 835.38 1017.45 percent of total billed charges "COMPUTED TOMOGRAPHY, THORAX, LOW DOSE FOR LUNG CANCER SCREENING, WITHOUT CONTRAST MATERIAL(S)" 3507127101_1 CDM 350 RC 71271 HCPCS outpatient 1071 803.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 953.19 89 999999999 835.38 1017.45 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 3601201801_1 CDM 360 RC 12018 HCPCS outpatient 572 429 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 514.8 999999999 446.16 543.4 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 3601201801_1 CDM 360 RC 12018 HCPCS outpatient 572 429 AETNA MCR ADV AETNA MCR ADV 446.16 78 999999999 446.16 543.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 3601201801_1 CDM 360 RC 12018 HCPCS outpatient 572 429 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 500.9 87.57 999999999 446.16 543.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 3601201801_1 CDM 360 RC 12018 HCPCS outpatient 572 429 COORDINATED CARE MCAID COORDINATED CARE MCAID 486.6 85.07 999999999 446.16 543.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 3601201801_1 CDM 360 RC 12018 HCPCS outpatient 572 429 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 486.6 85.07 999999999 446.16 543.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 3601201801_1 CDM 360 RC 12018 HCPCS outpatient 572 429 MOLINA MCAID MOLINA MCAID 477.05 83.4 999999999 446.16 543.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 3601201801_1 CDM 360 RC 12018 HCPCS outpatient 572 429 MOLINA MCR ADV MOLINA MCR ADV 509.08 89 999999999 446.16 543.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 3601201801_1 CDM 360 RC 12018 HCPCS outpatient 572 429 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 509.08 89 999999999 446.16 543.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 3601201801_1 CDM 360 RC 12018 HCPCS outpatient 572 429 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 509.08 89 999999999 446.16 543.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 3601201801_1 CDM 360 RC 12018 HCPCS outpatient 572 429 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 514.8 90 999999999 446.16 543.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 3601201801_1 CDM 360 RC 12018 HCPCS outpatient 572 429 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 543.4 95 999999999 446.16 543.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 3601201801_1 CDM 360 RC 12018 HCPCS outpatient 572 429 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 543.4 95 999999999 446.16 543.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 3601201801_1 CDM 360 RC 12018 HCPCS outpatient 572 429 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 509.08 89 999999999 446.16 543.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 3601201801_1 CDM 360 RC 12018 HCPCS outpatient 572 429 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 503.36 88 999999999 446.16 543.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM" 3601201801_1 CDM 360 RC 12018 HCPCS outpatient 572 429 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 509.08 89 999999999 446.16 543.4 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS" 3602420001_1 CDM 360 RC 24200 HCPCS outpatient 267 200.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 240.3 999999999 208.26 253.65 case rate "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS" 3602420001_1 CDM 360 RC 24200 HCPCS outpatient 267 200.25 AETNA MCR ADV AETNA MCR ADV 208.26 78 999999999 208.26 253.65 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS" 3602420001_1 CDM 360 RC 24200 HCPCS outpatient 267 200.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 233.81 87.57 999999999 208.26 253.65 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS" 3602420001_1 CDM 360 RC 24200 HCPCS outpatient 267 200.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 227.14 85.07 999999999 208.26 253.65 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS" 3602420001_1 CDM 360 RC 24200 HCPCS outpatient 267 200.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 227.14 85.07 999999999 208.26 253.65 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS" 3602420001_1 CDM 360 RC 24200 HCPCS outpatient 267 200.25 MOLINA MCAID MOLINA MCAID 222.68 83.4 999999999 208.26 253.65 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS" 3602420001_1 CDM 360 RC 24200 HCPCS outpatient 267 200.25 MOLINA MCR ADV MOLINA MCR ADV 237.63 89 999999999 208.26 253.65 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS" 3602420001_1 CDM 360 RC 24200 HCPCS outpatient 267 200.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 237.63 89 999999999 208.26 253.65 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS" 3602420001_1 CDM 360 RC 24200 HCPCS outpatient 267 200.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 237.63 89 999999999 208.26 253.65 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS" 3602420001_1 CDM 360 RC 24200 HCPCS outpatient 267 200.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 240.3 90 999999999 208.26 253.65 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS" 3602420001_1 CDM 360 RC 24200 HCPCS outpatient 267 200.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 253.65 95 999999999 208.26 253.65 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS" 3602420001_1 CDM 360 RC 24200 HCPCS outpatient 267 200.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 253.65 95 999999999 208.26 253.65 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS" 3602420001_1 CDM 360 RC 24200 HCPCS outpatient 267 200.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 237.63 89 999999999 208.26 253.65 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS" 3602420001_1 CDM 360 RC 24200 HCPCS outpatient 267 200.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 234.96 88 999999999 208.26 253.65 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS" 3602420001_1 CDM 360 RC 24200 HCPCS outpatient 267 200.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 237.63 89 999999999 208.26 253.65 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 3602420101_1 CDM 360 RC 24201 HCPCS outpatient 961 720.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 864.9 999999999 749.58 912.95 case rate "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 3602420101_1 CDM 360 RC 24201 HCPCS outpatient 961 720.75 AETNA MCR ADV AETNA MCR ADV 749.58 78 999999999 749.58 912.95 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 3602420101_1 CDM 360 RC 24201 HCPCS outpatient 961 720.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 841.55 87.57 999999999 749.58 912.95 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 3602420101_1 CDM 360 RC 24201 HCPCS outpatient 961 720.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 817.52 85.07 999999999 749.58 912.95 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 3602420101_1 CDM 360 RC 24201 HCPCS outpatient 961 720.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 817.52 85.07 999999999 749.58 912.95 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 3602420101_1 CDM 360 RC 24201 HCPCS outpatient 961 720.75 MOLINA MCAID MOLINA MCAID 801.47 83.4 999999999 749.58 912.95 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 3602420101_1 CDM 360 RC 24201 HCPCS outpatient 961 720.75 MOLINA MCR ADV MOLINA MCR ADV 855.29 89 999999999 749.58 912.95 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 3602420101_1 CDM 360 RC 24201 HCPCS outpatient 961 720.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 855.29 89 999999999 749.58 912.95 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 3602420101_1 CDM 360 RC 24201 HCPCS outpatient 961 720.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 855.29 89 999999999 749.58 912.95 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 3602420101_1 CDM 360 RC 24201 HCPCS outpatient 961 720.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 864.9 90 999999999 749.58 912.95 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 3602420101_1 CDM 360 RC 24201 HCPCS outpatient 961 720.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 912.95 95 999999999 749.58 912.95 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 3602420101_1 CDM 360 RC 24201 HCPCS outpatient 961 720.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 912.95 95 999999999 749.58 912.95 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 3602420101_1 CDM 360 RC 24201 HCPCS outpatient 961 720.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 855.29 89 999999999 749.58 912.95 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 3602420101_1 CDM 360 RC 24201 HCPCS outpatient 961 720.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 845.68 88 999999999 749.58 912.95 percent of total billed charges "REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR)" 3602420101_1 CDM 360 RC 24201 HCPCS outpatient 961 720.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 855.29 89 999999999 749.58 912.95 percent of total billed charges "OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION" 3602784601_1 CDM 360 RC 27846 HCPCS outpatient 267 200.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 240.3 999999999 208.26 253.65 case rate "OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION" 3602784601_1 CDM 360 RC 27846 HCPCS outpatient 267 200.25 AETNA MCR ADV AETNA MCR ADV 208.26 78 999999999 208.26 253.65 percent of total billed charges "OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION" 3602784601_1 CDM 360 RC 27846 HCPCS outpatient 267 200.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 233.81 87.57 999999999 208.26 253.65 percent of total billed charges "OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION" 3602784601_1 CDM 360 RC 27846 HCPCS outpatient 267 200.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 227.14 85.07 999999999 208.26 253.65 percent of total billed charges "OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION" 3602784601_1 CDM 360 RC 27846 HCPCS outpatient 267 200.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 227.14 85.07 999999999 208.26 253.65 percent of total billed charges "OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION" 3602784601_1 CDM 360 RC 27846 HCPCS outpatient 267 200.25 MOLINA MCAID MOLINA MCAID 222.68 83.4 999999999 208.26 253.65 percent of total billed charges "OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION" 3602784601_1 CDM 360 RC 27846 HCPCS outpatient 267 200.25 MOLINA MCR ADV MOLINA MCR ADV 237.63 89 999999999 208.26 253.65 percent of total billed charges "OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION" 3602784601_1 CDM 360 RC 27846 HCPCS outpatient 267 200.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 237.63 89 999999999 208.26 253.65 percent of total billed charges "OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION" 3602784601_1 CDM 360 RC 27846 HCPCS outpatient 267 200.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 237.63 89 999999999 208.26 253.65 percent of total billed charges "OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION" 3602784601_1 CDM 360 RC 27846 HCPCS outpatient 267 200.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 240.3 90 999999999 208.26 253.65 percent of total billed charges "OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION" 3602784601_1 CDM 360 RC 27846 HCPCS outpatient 267 200.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 253.65 95 999999999 208.26 253.65 percent of total billed charges "OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION" 3602784601_1 CDM 360 RC 27846 HCPCS outpatient 267 200.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 253.65 95 999999999 208.26 253.65 percent of total billed charges "OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION" 3602784601_1 CDM 360 RC 27846 HCPCS outpatient 267 200.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 237.63 89 999999999 208.26 253.65 percent of total billed charges "OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION" 3602784601_1 CDM 360 RC 27846 HCPCS outpatient 267 200.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 234.96 88 999999999 208.26 253.65 percent of total billed charges "OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION" 3602784601_1 CDM 360 RC 27846 HCPCS outpatient 267 200.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 237.63 89 999999999 208.26 253.65 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA 3606920501_1 CDM 360 RC 69205 HCPCS outpatient 389 291.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 350.1 999999999 303.42 369.55 case rate REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA 3606920501_1 CDM 360 RC 69205 HCPCS outpatient 389 291.75 AETNA MCR ADV AETNA MCR ADV 303.42 78 999999999 303.42 369.55 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA 3606920501_1 CDM 360 RC 69205 HCPCS outpatient 389 291.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 340.65 87.57 999999999 303.42 369.55 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA 3606920501_1 CDM 360 RC 69205 HCPCS outpatient 389 291.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 330.92 85.07 999999999 303.42 369.55 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA 3606920501_1 CDM 360 RC 69205 HCPCS outpatient 389 291.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 330.92 85.07 999999999 303.42 369.55 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA 3606920501_1 CDM 360 RC 69205 HCPCS outpatient 389 291.75 MOLINA MCAID MOLINA MCAID 324.43 83.4 999999999 303.42 369.55 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA 3606920501_1 CDM 360 RC 69205 HCPCS outpatient 389 291.75 MOLINA MCR ADV MOLINA MCR ADV 346.21 89 999999999 303.42 369.55 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA 3606920501_1 CDM 360 RC 69205 HCPCS outpatient 389 291.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 346.21 89 999999999 303.42 369.55 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA 3606920501_1 CDM 360 RC 69205 HCPCS outpatient 389 291.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 346.21 89 999999999 303.42 369.55 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA 3606920501_1 CDM 360 RC 69205 HCPCS outpatient 389 291.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 350.1 90 999999999 303.42 369.55 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA 3606920501_1 CDM 360 RC 69205 HCPCS outpatient 389 291.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 369.55 95 999999999 303.42 369.55 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA 3606920501_1 CDM 360 RC 69205 HCPCS outpatient 389 291.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 369.55 95 999999999 303.42 369.55 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA 3606920501_1 CDM 360 RC 69205 HCPCS outpatient 389 291.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 346.21 89 999999999 303.42 369.55 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA 3606920501_1 CDM 360 RC 69205 HCPCS outpatient 389 291.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 342.32 88 999999999 303.42 369.55 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA 3606920501_1 CDM 360 RC 69205 HCPCS outpatient 389 291.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 346.21 89 999999999 303.42 369.55 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 3616441701_1 CDM 361 RC 64417 HCPCS outpatient 919 689.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 827.1 999999999 716.82 873.05 case rate "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 3616441701_1 CDM 361 RC 64417 HCPCS outpatient 919 689.25 AETNA MCR ADV AETNA MCR ADV 716.82 78 999999999 716.82 873.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 3616441701_1 CDM 361 RC 64417 HCPCS outpatient 919 689.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 804.77 87.57 999999999 716.82 873.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 3616441701_1 CDM 361 RC 64417 HCPCS outpatient 919 689.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 781.79 85.07 999999999 716.82 873.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 3616441701_1 CDM 361 RC 64417 HCPCS outpatient 919 689.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 781.79 85.07 999999999 716.82 873.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 3616441701_1 CDM 361 RC 64417 HCPCS outpatient 919 689.25 MOLINA MCAID MOLINA MCAID 766.45 83.4 999999999 716.82 873.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 3616441701_1 CDM 361 RC 64417 HCPCS outpatient 919 689.25 MOLINA MCR ADV MOLINA MCR ADV 817.91 89 999999999 716.82 873.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 3616441701_1 CDM 361 RC 64417 HCPCS outpatient 919 689.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 817.91 89 999999999 716.82 873.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 3616441701_1 CDM 361 RC 64417 HCPCS outpatient 919 689.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 817.91 89 999999999 716.82 873.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 3616441701_1 CDM 361 RC 64417 HCPCS outpatient 919 689.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 827.1 90 999999999 716.82 873.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 3616441701_1 CDM 361 RC 64417 HCPCS outpatient 919 689.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 873.05 95 999999999 716.82 873.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 3616441701_1 CDM 361 RC 64417 HCPCS outpatient 919 689.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 873.05 95 999999999 716.82 873.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 3616441701_1 CDM 361 RC 64417 HCPCS outpatient 919 689.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 817.91 89 999999999 716.82 873.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 3616441701_1 CDM 361 RC 64417 HCPCS outpatient 919 689.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 808.72 88 999999999 716.82 873.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 3616441701_1 CDM 361 RC 64417 HCPCS outpatient 919 689.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 817.91 89 999999999 716.82 873.05 percent of total billed charges INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER 36556_1 CDM 361 RC 36556 HCPCS outpatient 251.31 188.48 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 226.18 999999999 196.02 238.74 case rate INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER 36556_1 CDM 361 RC 36556 HCPCS outpatient 251.31 188.48 AETNA MCR ADV AETNA MCR ADV 196.02 78 999999999 196.02 238.74 percent of total billed charges INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER 36556_1 CDM 361 RC 36556 HCPCS outpatient 251.31 188.48 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 220.07 87.57 999999999 196.02 238.74 percent of total billed charges INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER 36556_1 CDM 361 RC 36556 HCPCS outpatient 251.31 188.48 COORDINATED CARE MCAID COORDINATED CARE MCAID 213.79 85.07 999999999 196.02 238.74 percent of total billed charges INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER 36556_1 CDM 361 RC 36556 HCPCS outpatient 251.31 188.48 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 213.79 85.07 999999999 196.02 238.74 percent of total billed charges INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER 36556_1 CDM 361 RC 36556 HCPCS outpatient 251.31 188.48 MOLINA MCAID MOLINA MCAID 209.59 83.4 999999999 196.02 238.74 percent of total billed charges INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER 36556_1 CDM 361 RC 36556 HCPCS outpatient 251.31 188.48 MOLINA MCR ADV MOLINA MCR ADV 223.67 89 999999999 196.02 238.74 percent of total billed charges INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER 36556_1 CDM 361 RC 36556 HCPCS outpatient 251.31 188.48 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 223.67 89 999999999 196.02 238.74 percent of total billed charges INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER 36556_1 CDM 361 RC 36556 HCPCS outpatient 251.31 188.48 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 223.67 89 999999999 196.02 238.74 percent of total billed charges INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER 36556_1 CDM 361 RC 36556 HCPCS outpatient 251.31 188.48 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 226.18 90 999999999 196.02 238.74 percent of total billed charges INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER 36556_1 CDM 361 RC 36556 HCPCS outpatient 251.31 188.48 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 238.74 95 999999999 196.02 238.74 percent of total billed charges INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER 36556_1 CDM 361 RC 36556 HCPCS outpatient 251.31 188.48 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 238.74 95 999999999 196.02 238.74 percent of total billed charges INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER 36556_1 CDM 361 RC 36556 HCPCS outpatient 251.31 188.48 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 223.67 89 999999999 196.02 238.74 percent of total billed charges INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER 36556_1 CDM 361 RC 36556 HCPCS outpatient 251.31 188.48 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 221.15 88 999999999 196.02 238.74 percent of total billed charges INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER 36556_1 CDM 361 RC 36556 HCPCS outpatient 251.31 188.48 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 223.67 89 999999999 196.02 238.74 percent of total billed charges PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION 36680_1 CDM 360 RC 36680 HCPCS outpatient 175.26 131.45 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 157.73 999999999 136.7 166.5 case rate PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION 36680_1 CDM 360 RC 36680 HCPCS outpatient 175.26 131.45 AETNA MCR ADV AETNA MCR ADV 136.7 78 999999999 136.7 166.5 percent of total billed charges PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION 36680_1 CDM 360 RC 36680 HCPCS outpatient 175.26 131.45 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 153.48 87.57 999999999 136.7 166.5 percent of total billed charges PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION 36680_1 CDM 360 RC 36680 HCPCS outpatient 175.26 131.45 COORDINATED CARE MCAID COORDINATED CARE MCAID 149.09 85.07 999999999 136.7 166.5 percent of total billed charges PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION 36680_1 CDM 360 RC 36680 HCPCS outpatient 175.26 131.45 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 149.09 85.07 999999999 136.7 166.5 percent of total billed charges PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION 36680_1 CDM 360 RC 36680 HCPCS outpatient 175.26 131.45 MOLINA MCAID MOLINA MCAID 146.17 83.4 999999999 136.7 166.5 percent of total billed charges PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION 36680_1 CDM 360 RC 36680 HCPCS outpatient 175.26 131.45 MOLINA MCR ADV MOLINA MCR ADV 155.98 89 999999999 136.7 166.5 percent of total billed charges PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION 36680_1 CDM 360 RC 36680 HCPCS outpatient 175.26 131.45 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 155.98 89 999999999 136.7 166.5 percent of total billed charges PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION 36680_1 CDM 360 RC 36680 HCPCS outpatient 175.26 131.45 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 155.98 89 999999999 136.7 166.5 percent of total billed charges PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION 36680_1 CDM 360 RC 36680 HCPCS outpatient 175.26 131.45 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 157.73 90 999999999 136.7 166.5 percent of total billed charges PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION 36680_1 CDM 360 RC 36680 HCPCS outpatient 175.26 131.45 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 166.5 95 999999999 136.7 166.5 percent of total billed charges PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION 36680_1 CDM 360 RC 36680 HCPCS outpatient 175.26 131.45 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 166.5 95 999999999 136.7 166.5 percent of total billed charges PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION 36680_1 CDM 360 RC 36680 HCPCS outpatient 175.26 131.45 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 155.98 89 999999999 136.7 166.5 percent of total billed charges PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION 36680_1 CDM 360 RC 36680 HCPCS outpatient 175.26 131.45 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 154.23 88 999999999 136.7 166.5 percent of total billed charges PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION 36680_1 CDM 360 RC 36680 HCPCS outpatient 175.26 131.45 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 155.98 89 999999999 136.7 166.5 percent of total billed charges "BLOOD TYPING, SEROLOGIC; ANTIGEN TESTING OF DONOR BLOOD USING REAGENT SERUM, EACH ANTIGEN TEST" 3908690201_1 CDM 390 RC 86902 HCPCS outpatient 315 236.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 283.5 90 999999999 245.7 299.25 percent of total billed charges "BLOOD TYPING, SEROLOGIC; ANTIGEN TESTING OF DONOR BLOOD USING REAGENT SERUM, EACH ANTIGEN TEST" 3908690201_1 CDM 390 RC 86902 HCPCS outpatient 315 236.25 AETNA MCR ADV AETNA MCR ADV 245.7 78 999999999 245.7 299.25 percent of total billed charges "BLOOD TYPING, SEROLOGIC; ANTIGEN TESTING OF DONOR BLOOD USING REAGENT SERUM, EACH ANTIGEN TEST" 3908690201_1 CDM 390 RC 86902 HCPCS outpatient 315 236.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 275.85 87.57 999999999 245.7 299.25 percent of total billed charges "BLOOD TYPING, SEROLOGIC; ANTIGEN TESTING OF DONOR BLOOD USING REAGENT SERUM, EACH ANTIGEN TEST" 3908690201_1 CDM 390 RC 86902 HCPCS outpatient 315 236.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 267.97 85.07 999999999 245.7 299.25 percent of total billed charges "BLOOD TYPING, SEROLOGIC; ANTIGEN TESTING OF DONOR BLOOD USING REAGENT SERUM, EACH ANTIGEN TEST" 3908690201_1 CDM 390 RC 86902 HCPCS outpatient 315 236.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 267.97 85.07 999999999 245.7 299.25 percent of total billed charges "BLOOD TYPING, SEROLOGIC; ANTIGEN TESTING OF DONOR BLOOD USING REAGENT SERUM, EACH ANTIGEN TEST" 3908690201_1 CDM 390 RC 86902 HCPCS outpatient 315 236.25 MOLINA MCAID MOLINA MCAID 262.71 83.4 999999999 245.7 299.25 percent of total billed charges "BLOOD TYPING, SEROLOGIC; ANTIGEN TESTING OF DONOR BLOOD USING REAGENT SERUM, EACH ANTIGEN TEST" 3908690201_1 CDM 390 RC 86902 HCPCS outpatient 315 236.25 MOLINA MCR ADV MOLINA MCR ADV 280.35 89 999999999 245.7 299.25 percent of total billed charges "BLOOD TYPING, SEROLOGIC; ANTIGEN TESTING OF DONOR BLOOD USING REAGENT SERUM, EACH ANTIGEN TEST" 3908690201_1 CDM 390 RC 86902 HCPCS outpatient 315 236.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 280.35 89 999999999 245.7 299.25 percent of total billed charges "BLOOD TYPING, SEROLOGIC; ANTIGEN TESTING OF DONOR BLOOD USING REAGENT SERUM, EACH ANTIGEN TEST" 3908690201_1 CDM 390 RC 86902 HCPCS outpatient 315 236.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 280.35 89 999999999 245.7 299.25 percent of total billed charges "BLOOD TYPING, SEROLOGIC; ANTIGEN TESTING OF DONOR BLOOD USING REAGENT SERUM, EACH ANTIGEN TEST" 3908690201_1 CDM 390 RC 86902 HCPCS outpatient 315 236.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 283.5 90 999999999 245.7 299.25 percent of total billed charges "BLOOD TYPING, SEROLOGIC; ANTIGEN TESTING OF DONOR BLOOD USING REAGENT SERUM, EACH ANTIGEN TEST" 3908690201_1 CDM 390 RC 86902 HCPCS outpatient 315 236.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 299.25 95 999999999 245.7 299.25 percent of total billed charges "BLOOD TYPING, SEROLOGIC; ANTIGEN TESTING OF DONOR BLOOD USING REAGENT SERUM, EACH ANTIGEN TEST" 3908690201_1 CDM 390 RC 86902 HCPCS outpatient 315 236.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 299.25 95 999999999 245.7 299.25 percent of total billed charges "BLOOD TYPING, SEROLOGIC; ANTIGEN TESTING OF DONOR BLOOD USING REAGENT SERUM, EACH ANTIGEN TEST" 3908690201_1 CDM 390 RC 86902 HCPCS outpatient 315 236.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 280.35 89 999999999 245.7 299.25 percent of total billed charges "BLOOD TYPING, SEROLOGIC; ANTIGEN TESTING OF DONOR BLOOD USING REAGENT SERUM, EACH ANTIGEN TEST" 3908690201_1 CDM 390 RC 86902 HCPCS outpatient 315 236.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 277.2 88 999999999 245.7 299.25 percent of total billed charges "BLOOD TYPING, SEROLOGIC; ANTIGEN TESTING OF DONOR BLOOD USING REAGENT SERUM, EACH ANTIGEN TEST" 3908690201_1 CDM 390 RC 86902 HCPCS outpatient 315 236.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 280.35 89 999999999 245.7 299.25 percent of total billed charges "NASO- OR ORO-GASTRIC TUBE PLACEMENT, REQUIRING PHYSICIAN'S SKILL AND FLUOROSCOPIC GUIDANCE (INCLUDES FLUOROSCOPY, IMAGE DOCUMENTATION AND REPORT)" 43752_1 CDM 361 RC 43752 HCPCS outpatient 66 49.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 59.4 999999999 51.48 62.7 case rate "NASO- OR ORO-GASTRIC TUBE PLACEMENT, REQUIRING PHYSICIAN'S SKILL AND FLUOROSCOPIC GUIDANCE (INCLUDES FLUOROSCOPY, IMAGE DOCUMENTATION AND REPORT)" 43752_1 CDM 361 RC 43752 HCPCS outpatient 66 49.5 AETNA MCR ADV AETNA MCR ADV 51.48 78 999999999 51.48 62.7 percent of total billed charges "NASO- OR ORO-GASTRIC TUBE PLACEMENT, REQUIRING PHYSICIAN'S SKILL AND FLUOROSCOPIC GUIDANCE (INCLUDES FLUOROSCOPY, IMAGE DOCUMENTATION AND REPORT)" 43752_1 CDM 361 RC 43752 HCPCS outpatient 66 49.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 57.8 87.57 999999999 51.48 62.7 percent of total billed charges "NASO- OR ORO-GASTRIC TUBE PLACEMENT, REQUIRING PHYSICIAN'S SKILL AND FLUOROSCOPIC GUIDANCE (INCLUDES FLUOROSCOPY, IMAGE DOCUMENTATION AND REPORT)" 43752_1 CDM 361 RC 43752 HCPCS outpatient 66 49.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 56.15 85.07 999999999 51.48 62.7 percent of total billed charges "NASO- OR ORO-GASTRIC TUBE PLACEMENT, REQUIRING PHYSICIAN'S SKILL AND FLUOROSCOPIC GUIDANCE (INCLUDES FLUOROSCOPY, IMAGE DOCUMENTATION AND REPORT)" 43752_1 CDM 361 RC 43752 HCPCS outpatient 66 49.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 56.15 85.07 999999999 51.48 62.7 percent of total billed charges "NASO- OR ORO-GASTRIC TUBE PLACEMENT, REQUIRING PHYSICIAN'S SKILL AND FLUOROSCOPIC GUIDANCE (INCLUDES FLUOROSCOPY, IMAGE DOCUMENTATION AND REPORT)" 43752_1 CDM 361 RC 43752 HCPCS outpatient 66 49.5 MOLINA MCAID MOLINA MCAID 55.04 83.4 999999999 51.48 62.7 percent of total billed charges "NASO- OR ORO-GASTRIC TUBE PLACEMENT, REQUIRING PHYSICIAN'S SKILL AND FLUOROSCOPIC GUIDANCE (INCLUDES FLUOROSCOPY, IMAGE DOCUMENTATION AND REPORT)" 43752_1 CDM 361 RC 43752 HCPCS outpatient 66 49.5 MOLINA MCR ADV MOLINA MCR ADV 58.74 89 999999999 51.48 62.7 percent of total billed charges "NASO- OR ORO-GASTRIC TUBE PLACEMENT, REQUIRING PHYSICIAN'S SKILL AND FLUOROSCOPIC GUIDANCE (INCLUDES FLUOROSCOPY, IMAGE DOCUMENTATION AND REPORT)" 43752_1 CDM 361 RC 43752 HCPCS outpatient 66 49.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 58.74 89 999999999 51.48 62.7 percent of total billed charges "NASO- OR ORO-GASTRIC TUBE PLACEMENT, REQUIRING PHYSICIAN'S SKILL AND FLUOROSCOPIC GUIDANCE (INCLUDES FLUOROSCOPY, IMAGE DOCUMENTATION AND REPORT)" 43752_1 CDM 361 RC 43752 HCPCS outpatient 66 49.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 58.74 89 999999999 51.48 62.7 percent of total billed charges "NASO- OR ORO-GASTRIC TUBE PLACEMENT, REQUIRING PHYSICIAN'S SKILL AND FLUOROSCOPIC GUIDANCE (INCLUDES FLUOROSCOPY, IMAGE DOCUMENTATION AND REPORT)" 43752_1 CDM 361 RC 43752 HCPCS outpatient 66 49.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 59.4 90 999999999 51.48 62.7 percent of total billed charges "NASO- OR ORO-GASTRIC TUBE PLACEMENT, REQUIRING PHYSICIAN'S SKILL AND FLUOROSCOPIC GUIDANCE (INCLUDES FLUOROSCOPY, IMAGE DOCUMENTATION AND REPORT)" 43752_1 CDM 361 RC 43752 HCPCS outpatient 66 49.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 62.7 95 999999999 51.48 62.7 percent of total billed charges "NASO- OR ORO-GASTRIC TUBE PLACEMENT, REQUIRING PHYSICIAN'S SKILL AND FLUOROSCOPIC GUIDANCE (INCLUDES FLUOROSCOPY, IMAGE DOCUMENTATION AND REPORT)" 43752_1 CDM 361 RC 43752 HCPCS outpatient 66 49.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 62.7 95 999999999 51.48 62.7 percent of total billed charges "NASO- OR ORO-GASTRIC TUBE PLACEMENT, REQUIRING PHYSICIAN'S SKILL AND FLUOROSCOPIC GUIDANCE (INCLUDES FLUOROSCOPY, IMAGE DOCUMENTATION AND REPORT)" 43752_1 CDM 361 RC 43752 HCPCS outpatient 66 49.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 58.74 89 999999999 51.48 62.7 percent of total billed charges "NASO- OR ORO-GASTRIC TUBE PLACEMENT, REQUIRING PHYSICIAN'S SKILL AND FLUOROSCOPIC GUIDANCE (INCLUDES FLUOROSCOPY, IMAGE DOCUMENTATION AND REPORT)" 43752_1 CDM 361 RC 43752 HCPCS outpatient 66 49.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 58.08 88 999999999 51.48 62.7 percent of total billed charges "NASO- OR ORO-GASTRIC TUBE PLACEMENT, REQUIRING PHYSICIAN'S SKILL AND FLUOROSCOPIC GUIDANCE (INCLUDES FLUOROSCOPY, IMAGE DOCUMENTATION AND REPORT)" 43752_1 CDM 361 RC 43752 HCPCS outpatient 66 49.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 58.74 89 999999999 51.48 62.7 percent of total billed charges "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 4502725201_1 CDM 450 RC 27252 HCPCS both 1962 1471.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1765.8 999999999 1530.36 1863.9 case rate "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 4502725201_1 CDM 450 RC 27252 HCPCS both 1962 1471.5 AETNA MCR ADV AETNA MCR ADV 1530.36 78 999999999 1530.36 1863.9 percent of total billed charges "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 4502725201_1 CDM 450 RC 27252 HCPCS both 1962 1471.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1718.12 87.57 999999999 1530.36 1863.9 percent of total billed charges "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 4502725201_1 CDM 450 RC 27252 HCPCS both 1962 1471.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 1669.07 85.07 999999999 1530.36 1863.9 percent of total billed charges "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 4502725201_1 CDM 450 RC 27252 HCPCS both 1962 1471.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1669.07 85.07 999999999 1530.36 1863.9 percent of total billed charges "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 4502725201_1 CDM 450 RC 27252 HCPCS both 1962 1471.5 MOLINA MCAID MOLINA MCAID 1636.31 83.4 999999999 1530.36 1863.9 percent of total billed charges "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 4502725201_1 CDM 450 RC 27252 HCPCS both 1962 1471.5 MOLINA MCR ADV MOLINA MCR ADV 1746.18 89 999999999 1530.36 1863.9 percent of total billed charges "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 4502725201_1 CDM 450 RC 27252 HCPCS both 1962 1471.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1746.18 89 999999999 1530.36 1863.9 percent of total billed charges "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 4502725201_1 CDM 450 RC 27252 HCPCS both 1962 1471.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1746.18 89 999999999 1530.36 1863.9 percent of total billed charges "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 4502725201_1 CDM 450 RC 27252 HCPCS both 1962 1471.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1765.8 90 999999999 1530.36 1863.9 percent of total billed charges "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 4502725201_1 CDM 450 RC 27252 HCPCS both 1962 1471.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1863.9 95 999999999 1530.36 1863.9 percent of total billed charges "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 4502725201_1 CDM 450 RC 27252 HCPCS both 1962 1471.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1863.9 95 999999999 1530.36 1863.9 percent of total billed charges "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 4502725201_1 CDM 450 RC 27252 HCPCS both 1962 1471.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1746.18 89 999999999 1530.36 1863.9 percent of total billed charges "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 4502725201_1 CDM 450 RC 27252 HCPCS both 1962 1471.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1726.56 88 999999999 1530.36 1863.9 percent of total billed charges "CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA" 4502725201_1 CDM 450 RC 27252 HCPCS both 1962 1471.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1746.18 89 999999999 1530.36 1863.9 percent of total billed charges "CONTROL NASAL HEMORRHAGE, POSTERIOR, WITH POSTERIOR NASAL PACKS AND/OR CAUTERY, ANY METHOD; SUBSEQUENT" 4503090601_1 CDM 450 RC 30906 HCPCS both 263 197.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 236.7 999999999 205.14 249.85 case rate "CONTROL NASAL HEMORRHAGE, POSTERIOR, WITH POSTERIOR NASAL PACKS AND/OR CAUTERY, ANY METHOD; SUBSEQUENT" 4503090601_1 CDM 450 RC 30906 HCPCS both 263 197.25 AETNA MCR ADV AETNA MCR ADV 205.14 78 999999999 205.14 249.85 percent of total billed charges "CONTROL NASAL HEMORRHAGE, POSTERIOR, WITH POSTERIOR NASAL PACKS AND/OR CAUTERY, ANY METHOD; SUBSEQUENT" 4503090601_1 CDM 450 RC 30906 HCPCS both 263 197.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 230.31 87.57 999999999 205.14 249.85 percent of total billed charges "CONTROL NASAL HEMORRHAGE, POSTERIOR, WITH POSTERIOR NASAL PACKS AND/OR CAUTERY, ANY METHOD; SUBSEQUENT" 4503090601_1 CDM 450 RC 30906 HCPCS both 263 197.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 223.73 85.07 999999999 205.14 249.85 percent of total billed charges "CONTROL NASAL HEMORRHAGE, POSTERIOR, WITH POSTERIOR NASAL PACKS AND/OR CAUTERY, ANY METHOD; SUBSEQUENT" 4503090601_1 CDM 450 RC 30906 HCPCS both 263 197.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 223.73 85.07 999999999 205.14 249.85 percent of total billed charges "CONTROL NASAL HEMORRHAGE, POSTERIOR, WITH POSTERIOR NASAL PACKS AND/OR CAUTERY, ANY METHOD; SUBSEQUENT" 4503090601_1 CDM 450 RC 30906 HCPCS both 263 197.25 MOLINA MCAID MOLINA MCAID 219.34 83.4 999999999 205.14 249.85 percent of total billed charges "CONTROL NASAL HEMORRHAGE, POSTERIOR, WITH POSTERIOR NASAL PACKS AND/OR CAUTERY, ANY METHOD; SUBSEQUENT" 4503090601_1 CDM 450 RC 30906 HCPCS both 263 197.25 MOLINA MCR ADV MOLINA MCR ADV 234.07 89 999999999 205.14 249.85 percent of total billed charges "CONTROL NASAL HEMORRHAGE, POSTERIOR, WITH POSTERIOR NASAL PACKS AND/OR CAUTERY, ANY METHOD; SUBSEQUENT" 4503090601_1 CDM 450 RC 30906 HCPCS both 263 197.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 234.07 89 999999999 205.14 249.85 percent of total billed charges "CONTROL NASAL HEMORRHAGE, POSTERIOR, WITH POSTERIOR NASAL PACKS AND/OR CAUTERY, ANY METHOD; SUBSEQUENT" 4503090601_1 CDM 450 RC 30906 HCPCS both 263 197.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 234.07 89 999999999 205.14 249.85 percent of total billed charges "CONTROL NASAL HEMORRHAGE, POSTERIOR, WITH POSTERIOR NASAL PACKS AND/OR CAUTERY, ANY METHOD; SUBSEQUENT" 4503090601_1 CDM 450 RC 30906 HCPCS both 263 197.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 236.7 90 999999999 205.14 249.85 percent of total billed charges "CONTROL NASAL HEMORRHAGE, POSTERIOR, WITH POSTERIOR NASAL PACKS AND/OR CAUTERY, ANY METHOD; SUBSEQUENT" 4503090601_1 CDM 450 RC 30906 HCPCS both 263 197.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 249.85 95 999999999 205.14 249.85 percent of total billed charges "CONTROL NASAL HEMORRHAGE, POSTERIOR, WITH POSTERIOR NASAL PACKS AND/OR CAUTERY, ANY METHOD; SUBSEQUENT" 4503090601_1 CDM 450 RC 30906 HCPCS both 263 197.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 249.85 95 999999999 205.14 249.85 percent of total billed charges "CONTROL NASAL HEMORRHAGE, POSTERIOR, WITH POSTERIOR NASAL PACKS AND/OR CAUTERY, ANY METHOD; SUBSEQUENT" 4503090601_1 CDM 450 RC 30906 HCPCS both 263 197.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 234.07 89 999999999 205.14 249.85 percent of total billed charges "CONTROL NASAL HEMORRHAGE, POSTERIOR, WITH POSTERIOR NASAL PACKS AND/OR CAUTERY, ANY METHOD; SUBSEQUENT" 4503090601_1 CDM 450 RC 30906 HCPCS both 263 197.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 231.44 88 999999999 205.14 249.85 percent of total billed charges "CONTROL NASAL HEMORRHAGE, POSTERIOR, WITH POSTERIOR NASAL PACKS AND/OR CAUTERY, ANY METHOD; SUBSEQUENT" 4503090601_1 CDM 450 RC 30906 HCPCS both 263 197.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 234.07 89 999999999 205.14 249.85 percent of total billed charges "LARYNGOSCOPY, INDIRECT; DIAGNOSTIC (SEPARATE PROCEDURE)" 4503150501_1 CDM 450 RC 31505 HCPCS both 375 281.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 337.5 999999999 292.5 356.25 case rate "LARYNGOSCOPY, INDIRECT; DIAGNOSTIC (SEPARATE PROCEDURE)" 4503150501_1 CDM 450 RC 31505 HCPCS both 375 281.25 AETNA MCR ADV AETNA MCR ADV 292.5 78 999999999 292.5 356.25 percent of total billed charges "LARYNGOSCOPY, INDIRECT; DIAGNOSTIC (SEPARATE PROCEDURE)" 4503150501_1 CDM 450 RC 31505 HCPCS both 375 281.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 328.39 87.57 999999999 292.5 356.25 percent of total billed charges "LARYNGOSCOPY, INDIRECT; DIAGNOSTIC (SEPARATE PROCEDURE)" 4503150501_1 CDM 450 RC 31505 HCPCS both 375 281.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 319.01 85.07 999999999 292.5 356.25 percent of total billed charges "LARYNGOSCOPY, INDIRECT; DIAGNOSTIC (SEPARATE PROCEDURE)" 4503150501_1 CDM 450 RC 31505 HCPCS both 375 281.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 319.01 85.07 999999999 292.5 356.25 percent of total billed charges "LARYNGOSCOPY, INDIRECT; DIAGNOSTIC (SEPARATE PROCEDURE)" 4503150501_1 CDM 450 RC 31505 HCPCS both 375 281.25 MOLINA MCAID MOLINA MCAID 312.75 83.4 999999999 292.5 356.25 percent of total billed charges "LARYNGOSCOPY, INDIRECT; DIAGNOSTIC (SEPARATE PROCEDURE)" 4503150501_1 CDM 450 RC 31505 HCPCS both 375 281.25 MOLINA MCR ADV MOLINA MCR ADV 333.75 89 999999999 292.5 356.25 percent of total billed charges "LARYNGOSCOPY, INDIRECT; DIAGNOSTIC (SEPARATE PROCEDURE)" 4503150501_1 CDM 450 RC 31505 HCPCS both 375 281.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 333.75 89 999999999 292.5 356.25 percent of total billed charges "LARYNGOSCOPY, INDIRECT; DIAGNOSTIC (SEPARATE PROCEDURE)" 4503150501_1 CDM 450 RC 31505 HCPCS both 375 281.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 333.75 89 999999999 292.5 356.25 percent of total billed charges "LARYNGOSCOPY, INDIRECT; DIAGNOSTIC (SEPARATE PROCEDURE)" 4503150501_1 CDM 450 RC 31505 HCPCS both 375 281.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 337.5 90 999999999 292.5 356.25 percent of total billed charges "LARYNGOSCOPY, INDIRECT; DIAGNOSTIC (SEPARATE PROCEDURE)" 4503150501_1 CDM 450 RC 31505 HCPCS both 375 281.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 356.25 95 999999999 292.5 356.25 percent of total billed charges "LARYNGOSCOPY, INDIRECT; DIAGNOSTIC (SEPARATE PROCEDURE)" 4503150501_1 CDM 450 RC 31505 HCPCS both 375 281.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 356.25 95 999999999 292.5 356.25 percent of total billed charges "LARYNGOSCOPY, INDIRECT; DIAGNOSTIC (SEPARATE PROCEDURE)" 4503150501_1 CDM 450 RC 31505 HCPCS both 375 281.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 333.75 89 999999999 292.5 356.25 percent of total billed charges "LARYNGOSCOPY, INDIRECT; DIAGNOSTIC (SEPARATE PROCEDURE)" 4503150501_1 CDM 450 RC 31505 HCPCS both 375 281.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 330 88 999999999 292.5 356.25 percent of total billed charges "LARYNGOSCOPY, INDIRECT; DIAGNOSTIC (SEPARATE PROCEDURE)" 4503150501_1 CDM 450 RC 31505 HCPCS both 375 281.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 333.75 89 999999999 292.5 356.25 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30-74 MINUTES" 4509929101_1 CDM 450 RC 99291 HCPCS both 6985 5238.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 6286.5 90 999999999 5448.3 6635.75 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30-74 MINUTES" 4509929101_1 CDM 450 RC 99291 HCPCS both 6985 5238.75 AETNA MCR ADV AETNA MCR ADV 5448.3 78 999999999 5448.3 6635.75 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30-74 MINUTES" 4509929101_1 CDM 450 RC 99291 HCPCS both 6985 5238.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 6116.76 87.57 999999999 5448.3 6635.75 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30-74 MINUTES" 4509929101_1 CDM 450 RC 99291 HCPCS both 6985 5238.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 5942.14 85.07 999999999 5448.3 6635.75 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30-74 MINUTES" 4509929101_1 CDM 450 RC 99291 HCPCS both 6985 5238.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 5942.14 85.07 999999999 5448.3 6635.75 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30-74 MINUTES" 4509929101_1 CDM 450 RC 99291 HCPCS both 6985 5238.75 MOLINA MCAID MOLINA MCAID 5825.49 83.4 999999999 5448.3 6635.75 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30-74 MINUTES" 4509929101_1 CDM 450 RC 99291 HCPCS both 6985 5238.75 MOLINA MCR ADV MOLINA MCR ADV 6216.65 89 999999999 5448.3 6635.75 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30-74 MINUTES" 4509929101_1 CDM 450 RC 99291 HCPCS both 6985 5238.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 6216.65 89 999999999 5448.3 6635.75 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30-74 MINUTES" 4509929101_1 CDM 450 RC 99291 HCPCS both 6985 5238.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 6216.65 89 999999999 5448.3 6635.75 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30-74 MINUTES" 4509929101_1 CDM 450 RC 99291 HCPCS both 6985 5238.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 6286.5 90 999999999 5448.3 6635.75 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30-74 MINUTES" 4509929101_1 CDM 450 RC 99291 HCPCS both 6985 5238.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 6635.75 95 999999999 5448.3 6635.75 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30-74 MINUTES" 4509929101_1 CDM 450 RC 99291 HCPCS both 6985 5238.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 6635.75 95 999999999 5448.3 6635.75 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30-74 MINUTES" 4509929101_1 CDM 450 RC 99291 HCPCS both 6985 5238.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 6216.65 89 999999999 5448.3 6635.75 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30-74 MINUTES" 4509929101_1 CDM 450 RC 99291 HCPCS both 6985 5238.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 6146.8 88 999999999 5448.3 6635.75 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30-74 MINUTES" 4509929101_1 CDM 450 RC 99291 HCPCS both 6985 5238.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 6216.65 89 999999999 5448.3 6635.75 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30-74 MINUTES" 4509929101_2 CDM 450 RC 99291 HCPCS both 6985 5238.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 6286.5 90 999999999 5448.3 6635.75 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30-74 MINUTES" 4509929101_2 CDM 450 RC 99291 HCPCS both 6985 5238.75 AETNA MCR ADV AETNA MCR ADV 5448.3 78 999999999 5448.3 6635.75 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30-74 MINUTES" 4509929101_2 CDM 450 RC 99291 HCPCS both 6985 5238.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 6116.76 87.57 999999999 5448.3 6635.75 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30-74 MINUTES" 4509929101_2 CDM 450 RC 99291 HCPCS both 6985 5238.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 5942.14 85.07 999999999 5448.3 6635.75 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30-74 MINUTES" 4509929101_2 CDM 450 RC 99291 HCPCS both 6985 5238.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 5942.14 85.07 999999999 5448.3 6635.75 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30-74 MINUTES" 4509929101_2 CDM 450 RC 99291 HCPCS both 6985 5238.75 MOLINA MCAID MOLINA MCAID 5825.49 83.4 999999999 5448.3 6635.75 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30-74 MINUTES" 4509929101_2 CDM 450 RC 99291 HCPCS both 6985 5238.75 MOLINA MCR ADV MOLINA MCR ADV 6216.65 89 999999999 5448.3 6635.75 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30-74 MINUTES" 4509929101_2 CDM 450 RC 99291 HCPCS both 6985 5238.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 6216.65 89 999999999 5448.3 6635.75 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30-74 MINUTES" 4509929101_2 CDM 450 RC 99291 HCPCS both 6985 5238.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 6216.65 89 999999999 5448.3 6635.75 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30-74 MINUTES" 4509929101_2 CDM 450 RC 99291 HCPCS both 6985 5238.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 6286.5 90 999999999 5448.3 6635.75 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30-74 MINUTES" 4509929101_2 CDM 450 RC 99291 HCPCS both 6985 5238.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 6635.75 95 999999999 5448.3 6635.75 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30-74 MINUTES" 4509929101_2 CDM 450 RC 99291 HCPCS both 6985 5238.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 6635.75 95 999999999 5448.3 6635.75 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30-74 MINUTES" 4509929101_2 CDM 450 RC 99291 HCPCS both 6985 5238.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 6216.65 89 999999999 5448.3 6635.75 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30-74 MINUTES" 4509929101_2 CDM 450 RC 99291 HCPCS both 6985 5238.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 6146.8 88 999999999 5448.3 6635.75 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30-74 MINUTES" 4509929101_2 CDM 450 RC 99291 HCPCS both 6985 5238.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 6216.65 89 999999999 5448.3 6635.75 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 4509929201_1 CDM 450 RC 99292 HCPCS both 1213 909.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1091.7 90 999999999 946.14 1152.35 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 4509929201_1 CDM 450 RC 99292 HCPCS both 1213 909.75 AETNA MCR ADV AETNA MCR ADV 946.14 78 999999999 946.14 1152.35 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 4509929201_1 CDM 450 RC 99292 HCPCS both 1213 909.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1062.22 87.57 999999999 946.14 1152.35 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 4509929201_1 CDM 450 RC 99292 HCPCS both 1213 909.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 1031.9 85.07 999999999 946.14 1152.35 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 4509929201_1 CDM 450 RC 99292 HCPCS both 1213 909.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1031.9 85.07 999999999 946.14 1152.35 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 4509929201_1 CDM 450 RC 99292 HCPCS both 1213 909.75 MOLINA MCAID MOLINA MCAID 1011.64 83.4 999999999 946.14 1152.35 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 4509929201_1 CDM 450 RC 99292 HCPCS both 1213 909.75 MOLINA MCR ADV MOLINA MCR ADV 1079.57 89 999999999 946.14 1152.35 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 4509929201_1 CDM 450 RC 99292 HCPCS both 1213 909.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1079.57 89 999999999 946.14 1152.35 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 4509929201_1 CDM 450 RC 99292 HCPCS both 1213 909.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1079.57 89 999999999 946.14 1152.35 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 4509929201_1 CDM 450 RC 99292 HCPCS both 1213 909.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1091.7 90 999999999 946.14 1152.35 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 4509929201_1 CDM 450 RC 99292 HCPCS both 1213 909.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1152.35 95 999999999 946.14 1152.35 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 4509929201_1 CDM 450 RC 99292 HCPCS both 1213 909.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1152.35 95 999999999 946.14 1152.35 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 4509929201_1 CDM 450 RC 99292 HCPCS both 1213 909.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1079.57 89 999999999 946.14 1152.35 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 4509929201_1 CDM 450 RC 99292 HCPCS both 1213 909.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1067.44 88 999999999 946.14 1152.35 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 4509929201_1 CDM 450 RC 99292 HCPCS both 1213 909.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1079.57 89 999999999 946.14 1152.35 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 4509929201_2 CDM 450 RC 99292 HCPCS both 1213 909.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1091.7 90 999999999 946.14 1152.35 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 4509929201_2 CDM 450 RC 99292 HCPCS both 1213 909.75 AETNA MCR ADV AETNA MCR ADV 946.14 78 999999999 946.14 1152.35 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 4509929201_2 CDM 450 RC 99292 HCPCS both 1213 909.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1062.22 87.57 999999999 946.14 1152.35 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 4509929201_2 CDM 450 RC 99292 HCPCS both 1213 909.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 1031.9 85.07 999999999 946.14 1152.35 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 4509929201_2 CDM 450 RC 99292 HCPCS both 1213 909.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1031.9 85.07 999999999 946.14 1152.35 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 4509929201_2 CDM 450 RC 99292 HCPCS both 1213 909.75 MOLINA MCAID MOLINA MCAID 1011.64 83.4 999999999 946.14 1152.35 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 4509929201_2 CDM 450 RC 99292 HCPCS both 1213 909.75 MOLINA MCR ADV MOLINA MCR ADV 1079.57 89 999999999 946.14 1152.35 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 4509929201_2 CDM 450 RC 99292 HCPCS both 1213 909.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1079.57 89 999999999 946.14 1152.35 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 4509929201_2 CDM 450 RC 99292 HCPCS both 1213 909.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1079.57 89 999999999 946.14 1152.35 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 4509929201_2 CDM 450 RC 99292 HCPCS both 1213 909.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1091.7 90 999999999 946.14 1152.35 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 4509929201_2 CDM 450 RC 99292 HCPCS both 1213 909.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1152.35 95 999999999 946.14 1152.35 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 4509929201_2 CDM 450 RC 99292 HCPCS both 1213 909.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1152.35 95 999999999 946.14 1152.35 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 4509929201_2 CDM 450 RC 99292 HCPCS both 1213 909.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1079.57 89 999999999 946.14 1152.35 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 4509929201_2 CDM 450 RC 99292 HCPCS both 1213 909.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1067.44 88 999999999 946.14 1152.35 percent of total billed charges "CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 4509929201_2 CDM 450 RC 99292 HCPCS both 1213 909.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1079.57 89 999999999 946.14 1152.35 percent of total billed charges "INCISION OF THROMBOSED HEMORRHOID, EXTERNAL" 46083_3 CDM 360 RC 46083 HCPCS outpatient 420 315 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 378 999999999 327.6 399 case rate "INCISION OF THROMBOSED HEMORRHOID, EXTERNAL" 46083_3 CDM 360 RC 46083 HCPCS outpatient 420 315 AETNA MCR ADV AETNA MCR ADV 327.6 78 999999999 327.6 399 percent of total billed charges "INCISION OF THROMBOSED HEMORRHOID, EXTERNAL" 46083_3 CDM 360 RC 46083 HCPCS outpatient 420 315 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 367.79 87.57 999999999 327.6 399 percent of total billed charges "INCISION OF THROMBOSED HEMORRHOID, EXTERNAL" 46083_3 CDM 360 RC 46083 HCPCS outpatient 420 315 COORDINATED CARE MCAID COORDINATED CARE MCAID 357.29 85.07 999999999 327.6 399 percent of total billed charges "INCISION OF THROMBOSED HEMORRHOID, EXTERNAL" 46083_3 CDM 360 RC 46083 HCPCS outpatient 420 315 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 357.29 85.07 999999999 327.6 399 percent of total billed charges "INCISION OF THROMBOSED HEMORRHOID, EXTERNAL" 46083_3 CDM 360 RC 46083 HCPCS outpatient 420 315 MOLINA MCAID MOLINA MCAID 350.28 83.4 999999999 327.6 399 percent of total billed charges "INCISION OF THROMBOSED HEMORRHOID, EXTERNAL" 46083_3 CDM 360 RC 46083 HCPCS outpatient 420 315 MOLINA MCR ADV MOLINA MCR ADV 373.8 89 999999999 327.6 399 percent of total billed charges "INCISION OF THROMBOSED HEMORRHOID, EXTERNAL" 46083_3 CDM 360 RC 46083 HCPCS outpatient 420 315 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 373.8 89 999999999 327.6 399 percent of total billed charges "INCISION OF THROMBOSED HEMORRHOID, EXTERNAL" 46083_3 CDM 360 RC 46083 HCPCS outpatient 420 315 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 373.8 89 999999999 327.6 399 percent of total billed charges "INCISION OF THROMBOSED HEMORRHOID, EXTERNAL" 46083_3 CDM 360 RC 46083 HCPCS outpatient 420 315 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 378 90 999999999 327.6 399 percent of total billed charges "INCISION OF THROMBOSED HEMORRHOID, EXTERNAL" 46083_3 CDM 360 RC 46083 HCPCS outpatient 420 315 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 399 95 999999999 327.6 399 percent of total billed charges "INCISION OF THROMBOSED HEMORRHOID, EXTERNAL" 46083_3 CDM 360 RC 46083 HCPCS outpatient 420 315 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 399 95 999999999 327.6 399 percent of total billed charges "INCISION OF THROMBOSED HEMORRHOID, EXTERNAL" 46083_3 CDM 360 RC 46083 HCPCS outpatient 420 315 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 373.8 89 999999999 327.6 399 percent of total billed charges "INCISION OF THROMBOSED HEMORRHOID, EXTERNAL" 46083_3 CDM 360 RC 46083 HCPCS outpatient 420 315 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 369.6 88 999999999 327.6 399 percent of total billed charges "INCISION OF THROMBOSED HEMORRHOID, EXTERNAL" 46083_3 CDM 360 RC 46083 HCPCS outpatient 420 315 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 373.8 89 999999999 327.6 399 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GREATER OCCIPITAL NERVE" 5106440501_1 CDM 510 RC 64405 HCPCS outpatient 919 689.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 827.1 999999999 716.82 873.05 case rate "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GREATER OCCIPITAL NERVE" 5106440501_1 CDM 510 RC 64405 HCPCS outpatient 919 689.25 AETNA MCR ADV AETNA MCR ADV 716.82 78 999999999 716.82 873.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GREATER OCCIPITAL NERVE" 5106440501_1 CDM 510 RC 64405 HCPCS outpatient 919 689.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 804.77 87.57 999999999 716.82 873.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GREATER OCCIPITAL NERVE" 5106440501_1 CDM 510 RC 64405 HCPCS outpatient 919 689.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 781.79 85.07 999999999 716.82 873.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GREATER OCCIPITAL NERVE" 5106440501_1 CDM 510 RC 64405 HCPCS outpatient 919 689.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 781.79 85.07 999999999 716.82 873.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GREATER OCCIPITAL NERVE" 5106440501_1 CDM 510 RC 64405 HCPCS outpatient 919 689.25 MOLINA MCAID MOLINA MCAID 766.45 83.4 999999999 716.82 873.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GREATER OCCIPITAL NERVE" 5106440501_1 CDM 510 RC 64405 HCPCS outpatient 919 689.25 MOLINA MCR ADV MOLINA MCR ADV 817.91 89 999999999 716.82 873.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GREATER OCCIPITAL NERVE" 5106440501_1 CDM 510 RC 64405 HCPCS outpatient 919 689.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 817.91 89 999999999 716.82 873.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GREATER OCCIPITAL NERVE" 5106440501_1 CDM 510 RC 64405 HCPCS outpatient 919 689.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 817.91 89 999999999 716.82 873.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GREATER OCCIPITAL NERVE" 5106440501_1 CDM 510 RC 64405 HCPCS outpatient 919 689.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 827.1 90 999999999 716.82 873.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GREATER OCCIPITAL NERVE" 5106440501_1 CDM 510 RC 64405 HCPCS outpatient 919 689.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 999999999 716.82 873.05 other Non-Covered [Rev Code] ( 1*0 ) Term Line 16 "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GREATER OCCIPITAL NERVE" 5106440501_1 CDM 510 RC 64405 HCPCS outpatient 919 689.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 873.05 95 999999999 716.82 873.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GREATER OCCIPITAL NERVE" 5106440501_1 CDM 510 RC 64405 HCPCS outpatient 919 689.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 817.91 89 999999999 716.82 873.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GREATER OCCIPITAL NERVE" 5106440501_1 CDM 510 RC 64405 HCPCS outpatient 919 689.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 808.72 88 999999999 716.82 873.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GREATER OCCIPITAL NERVE" 5106440501_1 CDM 510 RC 64405 HCPCS outpatient 919 689.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 817.91 89 999999999 716.82 873.05 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 51700_1 CDM 360 RC 51700 HCPCS outpatient 91.35 68.51 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 82.22 999999999 71.25 86.78 case rate "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 51700_1 CDM 360 RC 51700 HCPCS outpatient 91.35 68.51 AETNA MCR ADV AETNA MCR ADV 71.25 78 999999999 71.25 86.78 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 51700_1 CDM 360 RC 51700 HCPCS outpatient 91.35 68.51 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 80 87.57 999999999 71.25 86.78 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 51700_1 CDM 360 RC 51700 HCPCS outpatient 91.35 68.51 COORDINATED CARE MCAID COORDINATED CARE MCAID 77.71 85.07 999999999 71.25 86.78 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 51700_1 CDM 360 RC 51700 HCPCS outpatient 91.35 68.51 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 77.71 85.07 999999999 71.25 86.78 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 51700_1 CDM 360 RC 51700 HCPCS outpatient 91.35 68.51 MOLINA MCAID MOLINA MCAID 76.19 83.4 999999999 71.25 86.78 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 51700_1 CDM 360 RC 51700 HCPCS outpatient 91.35 68.51 MOLINA MCR ADV MOLINA MCR ADV 81.3 89 999999999 71.25 86.78 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 51700_1 CDM 360 RC 51700 HCPCS outpatient 91.35 68.51 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 81.3 89 999999999 71.25 86.78 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 51700_1 CDM 360 RC 51700 HCPCS outpatient 91.35 68.51 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 81.3 89 999999999 71.25 86.78 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 51700_1 CDM 360 RC 51700 HCPCS outpatient 91.35 68.51 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 82.22 90 999999999 71.25 86.78 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 51700_1 CDM 360 RC 51700 HCPCS outpatient 91.35 68.51 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 86.78 95 999999999 71.25 86.78 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 51700_1 CDM 360 RC 51700 HCPCS outpatient 91.35 68.51 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 86.78 95 999999999 71.25 86.78 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 51700_1 CDM 360 RC 51700 HCPCS outpatient 91.35 68.51 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 81.3 89 999999999 71.25 86.78 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 51700_1 CDM 360 RC 51700 HCPCS outpatient 91.35 68.51 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 80.39 88 999999999 71.25 86.78 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 51700_1 CDM 360 RC 51700 HCPCS outpatient 91.35 68.51 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 81.3 89 999999999 71.25 86.78 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 51700_3 CDM 360 RC 51700 HCPCS outpatient 158 118.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 142.2 999999999 123.24 150.1 case rate "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 51700_3 CDM 360 RC 51700 HCPCS outpatient 158 118.5 AETNA MCR ADV AETNA MCR ADV 123.24 78 999999999 123.24 150.1 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 51700_3 CDM 360 RC 51700 HCPCS outpatient 158 118.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 138.36 87.57 999999999 123.24 150.1 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 51700_3 CDM 360 RC 51700 HCPCS outpatient 158 118.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 134.41 85.07 999999999 123.24 150.1 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 51700_3 CDM 360 RC 51700 HCPCS outpatient 158 118.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 134.41 85.07 999999999 123.24 150.1 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 51700_3 CDM 360 RC 51700 HCPCS outpatient 158 118.5 MOLINA MCAID MOLINA MCAID 131.77 83.4 999999999 123.24 150.1 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 51700_3 CDM 360 RC 51700 HCPCS outpatient 158 118.5 MOLINA MCR ADV MOLINA MCR ADV 140.62 89 999999999 123.24 150.1 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 51700_3 CDM 360 RC 51700 HCPCS outpatient 158 118.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 140.62 89 999999999 123.24 150.1 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 51700_3 CDM 360 RC 51700 HCPCS outpatient 158 118.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 140.62 89 999999999 123.24 150.1 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 51700_3 CDM 360 RC 51700 HCPCS outpatient 158 118.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 142.2 90 999999999 123.24 150.1 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 51700_3 CDM 360 RC 51700 HCPCS outpatient 158 118.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 150.1 95 999999999 123.24 150.1 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 51700_3 CDM 360 RC 51700 HCPCS outpatient 158 118.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 150.1 95 999999999 123.24 150.1 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 51700_3 CDM 360 RC 51700 HCPCS outpatient 158 118.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 140.62 89 999999999 123.24 150.1 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 51700_3 CDM 360 RC 51700 HCPCS outpatient 158 118.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 139.04 88 999999999 123.24 150.1 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 51700_3 CDM 360 RC 51700 HCPCS outpatient 158 118.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 140.62 89 999999999 123.24 150.1 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 51701_1 CDM 360 RC 51701 HCPCS outpatient 77.04 57.78 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 69.34 999999999 60.09 73.19 case rate "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 51701_1 CDM 360 RC 51701 HCPCS outpatient 77.04 57.78 AETNA MCR ADV AETNA MCR ADV 60.09 78 999999999 60.09 73.19 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 51701_1 CDM 360 RC 51701 HCPCS outpatient 77.04 57.78 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 67.46 87.57 999999999 60.09 73.19 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 51701_1 CDM 360 RC 51701 HCPCS outpatient 77.04 57.78 COORDINATED CARE MCAID COORDINATED CARE MCAID 65.54 85.07 999999999 60.09 73.19 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 51701_1 CDM 360 RC 51701 HCPCS outpatient 77.04 57.78 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 65.54 85.07 999999999 60.09 73.19 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 51701_1 CDM 360 RC 51701 HCPCS outpatient 77.04 57.78 MOLINA MCAID MOLINA MCAID 64.25 83.4 999999999 60.09 73.19 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 51701_1 CDM 360 RC 51701 HCPCS outpatient 77.04 57.78 MOLINA MCR ADV MOLINA MCR ADV 68.57 89 999999999 60.09 73.19 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 51701_1 CDM 360 RC 51701 HCPCS outpatient 77.04 57.78 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 68.57 89 999999999 60.09 73.19 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 51701_1 CDM 360 RC 51701 HCPCS outpatient 77.04 57.78 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 68.57 89 999999999 60.09 73.19 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 51701_1 CDM 360 RC 51701 HCPCS outpatient 77.04 57.78 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 69.34 90 999999999 60.09 73.19 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 51701_1 CDM 360 RC 51701 HCPCS outpatient 77.04 57.78 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 73.19 95 999999999 60.09 73.19 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 51701_1 CDM 360 RC 51701 HCPCS outpatient 77.04 57.78 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 73.19 95 999999999 60.09 73.19 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 51701_1 CDM 360 RC 51701 HCPCS outpatient 77.04 57.78 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 68.57 89 999999999 60.09 73.19 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 51701_1 CDM 360 RC 51701 HCPCS outpatient 77.04 57.78 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 67.8 88 999999999 60.09 73.19 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 51701_1 CDM 360 RC 51701 HCPCS outpatient 77.04 57.78 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 68.57 89 999999999 60.09 73.19 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 51701_3 CDM 360 RC 51701 HCPCS outpatient 92 69 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 82.8 999999999 71.76 87.4 case rate "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 51701_3 CDM 360 RC 51701 HCPCS outpatient 92 69 AETNA MCR ADV AETNA MCR ADV 71.76 78 999999999 71.76 87.4 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 51701_3 CDM 360 RC 51701 HCPCS outpatient 92 69 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 80.56 87.57 999999999 71.76 87.4 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 51701_3 CDM 360 RC 51701 HCPCS outpatient 92 69 COORDINATED CARE MCAID COORDINATED CARE MCAID 78.26 85.07 999999999 71.76 87.4 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 51701_3 CDM 360 RC 51701 HCPCS outpatient 92 69 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 78.26 85.07 999999999 71.76 87.4 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 51701_3 CDM 360 RC 51701 HCPCS outpatient 92 69 MOLINA MCAID MOLINA MCAID 76.73 83.4 999999999 71.76 87.4 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 51701_3 CDM 360 RC 51701 HCPCS outpatient 92 69 MOLINA MCR ADV MOLINA MCR ADV 81.88 89 999999999 71.76 87.4 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 51701_3 CDM 360 RC 51701 HCPCS outpatient 92 69 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 81.88 89 999999999 71.76 87.4 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 51701_3 CDM 360 RC 51701 HCPCS outpatient 92 69 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 81.88 89 999999999 71.76 87.4 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 51701_3 CDM 360 RC 51701 HCPCS outpatient 92 69 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 82.8 90 999999999 71.76 87.4 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 51701_3 CDM 360 RC 51701 HCPCS outpatient 92 69 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 87.4 95 999999999 71.76 87.4 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 51701_3 CDM 360 RC 51701 HCPCS outpatient 92 69 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 87.4 95 999999999 71.76 87.4 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 51701_3 CDM 360 RC 51701 HCPCS outpatient 92 69 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 81.88 89 999999999 71.76 87.4 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 51701_3 CDM 360 RC 51701 HCPCS outpatient 92 69 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 80.96 88 999999999 71.76 87.4 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 51701_3 CDM 360 RC 51701 HCPCS outpatient 92 69 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 81.88 89 999999999 71.76 87.4 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_1 CDM 360 RC 51702 HCPCS outpatient 76.26 57.2 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 68.63 999999999 59.48 72.45 case rate "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_1 CDM 360 RC 51702 HCPCS outpatient 76.26 57.2 AETNA MCR ADV AETNA MCR ADV 59.48 78 999999999 59.48 72.45 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_1 CDM 360 RC 51702 HCPCS outpatient 76.26 57.2 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 66.78 87.57 999999999 59.48 72.45 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_1 CDM 360 RC 51702 HCPCS outpatient 76.26 57.2 COORDINATED CARE MCAID COORDINATED CARE MCAID 64.87 85.07 999999999 59.48 72.45 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_1 CDM 360 RC 51702 HCPCS outpatient 76.26 57.2 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 64.87 85.07 999999999 59.48 72.45 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_1 CDM 360 RC 51702 HCPCS outpatient 76.26 57.2 MOLINA MCAID MOLINA MCAID 63.6 83.4 999999999 59.48 72.45 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_1 CDM 360 RC 51702 HCPCS outpatient 76.26 57.2 MOLINA MCR ADV MOLINA MCR ADV 67.87 89 999999999 59.48 72.45 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_1 CDM 360 RC 51702 HCPCS outpatient 76.26 57.2 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 67.87 89 999999999 59.48 72.45 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_1 CDM 360 RC 51702 HCPCS outpatient 76.26 57.2 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 67.87 89 999999999 59.48 72.45 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_1 CDM 360 RC 51702 HCPCS outpatient 76.26 57.2 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 68.63 90 999999999 59.48 72.45 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_1 CDM 360 RC 51702 HCPCS outpatient 76.26 57.2 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 72.45 95 999999999 59.48 72.45 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_1 CDM 360 RC 51702 HCPCS outpatient 76.26 57.2 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 72.45 95 999999999 59.48 72.45 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_1 CDM 360 RC 51702 HCPCS outpatient 76.26 57.2 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 67.87 89 999999999 59.48 72.45 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_1 CDM 360 RC 51702 HCPCS outpatient 76.26 57.2 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 67.11 88 999999999 59.48 72.45 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_1 CDM 360 RC 51702 HCPCS outpatient 76.26 57.2 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 67.87 89 999999999 59.48 72.45 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_2 CDM 360 RC 51702 HCPCS outpatient 76.26 57.2 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 68.63 999999999 59.48 72.45 case rate "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_2 CDM 360 RC 51702 HCPCS outpatient 76.26 57.2 AETNA MCR ADV AETNA MCR ADV 59.48 78 999999999 59.48 72.45 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_2 CDM 360 RC 51702 HCPCS outpatient 76.26 57.2 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 66.78 87.57 999999999 59.48 72.45 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_2 CDM 360 RC 51702 HCPCS outpatient 76.26 57.2 COORDINATED CARE MCAID COORDINATED CARE MCAID 64.87 85.07 999999999 59.48 72.45 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_2 CDM 360 RC 51702 HCPCS outpatient 76.26 57.2 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 64.87 85.07 999999999 59.48 72.45 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_2 CDM 360 RC 51702 HCPCS outpatient 76.26 57.2 MOLINA MCAID MOLINA MCAID 63.6 83.4 999999999 59.48 72.45 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_2 CDM 360 RC 51702 HCPCS outpatient 76.26 57.2 MOLINA MCR ADV MOLINA MCR ADV 67.87 89 999999999 59.48 72.45 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_2 CDM 360 RC 51702 HCPCS outpatient 76.26 57.2 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 67.87 89 999999999 59.48 72.45 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_2 CDM 360 RC 51702 HCPCS outpatient 76.26 57.2 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 67.87 89 999999999 59.48 72.45 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_2 CDM 360 RC 51702 HCPCS outpatient 76.26 57.2 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 68.63 90 999999999 59.48 72.45 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_2 CDM 360 RC 51702 HCPCS outpatient 76.26 57.2 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 72.45 95 999999999 59.48 72.45 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_2 CDM 360 RC 51702 HCPCS outpatient 76.26 57.2 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 72.45 95 999999999 59.48 72.45 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_2 CDM 360 RC 51702 HCPCS outpatient 76.26 57.2 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 67.87 89 999999999 59.48 72.45 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_2 CDM 360 RC 51702 HCPCS outpatient 76.26 57.2 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 67.11 88 999999999 59.48 72.45 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_2 CDM 360 RC 51702 HCPCS outpatient 76.26 57.2 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 67.87 89 999999999 59.48 72.45 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_3 CDM 360 RC 51702 HCPCS outpatient 159 119.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 143.1 999999999 124.02 151.05 case rate "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_3 CDM 360 RC 51702 HCPCS outpatient 159 119.25 AETNA MCR ADV AETNA MCR ADV 124.02 78 999999999 124.02 151.05 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_3 CDM 360 RC 51702 HCPCS outpatient 159 119.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 139.24 87.57 999999999 124.02 151.05 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_3 CDM 360 RC 51702 HCPCS outpatient 159 119.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 135.26 85.07 999999999 124.02 151.05 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_3 CDM 360 RC 51702 HCPCS outpatient 159 119.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 135.26 85.07 999999999 124.02 151.05 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_3 CDM 360 RC 51702 HCPCS outpatient 159 119.25 MOLINA MCAID MOLINA MCAID 132.61 83.4 999999999 124.02 151.05 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_3 CDM 360 RC 51702 HCPCS outpatient 159 119.25 MOLINA MCR ADV MOLINA MCR ADV 141.51 89 999999999 124.02 151.05 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_3 CDM 360 RC 51702 HCPCS outpatient 159 119.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 141.51 89 999999999 124.02 151.05 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_3 CDM 360 RC 51702 HCPCS outpatient 159 119.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 141.51 89 999999999 124.02 151.05 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_3 CDM 360 RC 51702 HCPCS outpatient 159 119.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 143.1 90 999999999 124.02 151.05 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_3 CDM 360 RC 51702 HCPCS outpatient 159 119.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 151.05 95 999999999 124.02 151.05 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_3 CDM 360 RC 51702 HCPCS outpatient 159 119.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 151.05 95 999999999 124.02 151.05 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_3 CDM 360 RC 51702 HCPCS outpatient 159 119.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 141.51 89 999999999 124.02 151.05 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_3 CDM 360 RC 51702 HCPCS outpatient 159 119.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 139.92 88 999999999 124.02 151.05 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 51702_3 CDM 360 RC 51702 HCPCS outpatient 159 119.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 141.51 89 999999999 124.02 151.05 percent of total billed charges CHANGE OF CYSTOSTOMY TUBE; SIMPLE 51705_1 CDM 360 RC 51705 HCPCS outpatient 153.51 115.13 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 138.16 999999999 119.74 145.83 case rate CHANGE OF CYSTOSTOMY TUBE; SIMPLE 51705_1 CDM 360 RC 51705 HCPCS outpatient 153.51 115.13 AETNA MCR ADV AETNA MCR ADV 119.74 78 999999999 119.74 145.83 percent of total billed charges CHANGE OF CYSTOSTOMY TUBE; SIMPLE 51705_1 CDM 360 RC 51705 HCPCS outpatient 153.51 115.13 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 134.43 87.57 999999999 119.74 145.83 percent of total billed charges CHANGE OF CYSTOSTOMY TUBE; SIMPLE 51705_1 CDM 360 RC 51705 HCPCS outpatient 153.51 115.13 COORDINATED CARE MCAID COORDINATED CARE MCAID 130.59 85.07 999999999 119.74 145.83 percent of total billed charges CHANGE OF CYSTOSTOMY TUBE; SIMPLE 51705_1 CDM 360 RC 51705 HCPCS outpatient 153.51 115.13 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 130.59 85.07 999999999 119.74 145.83 percent of total billed charges CHANGE OF CYSTOSTOMY TUBE; SIMPLE 51705_1 CDM 360 RC 51705 HCPCS outpatient 153.51 115.13 MOLINA MCAID MOLINA MCAID 128.03 83.4 999999999 119.74 145.83 percent of total billed charges CHANGE OF CYSTOSTOMY TUBE; SIMPLE 51705_1 CDM 360 RC 51705 HCPCS outpatient 153.51 115.13 MOLINA MCR ADV MOLINA MCR ADV 136.62 89 999999999 119.74 145.83 percent of total billed charges CHANGE OF CYSTOSTOMY TUBE; SIMPLE 51705_1 CDM 360 RC 51705 HCPCS outpatient 153.51 115.13 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 136.62 89 999999999 119.74 145.83 percent of total billed charges CHANGE OF CYSTOSTOMY TUBE; SIMPLE 51705_1 CDM 360 RC 51705 HCPCS outpatient 153.51 115.13 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 136.62 89 999999999 119.74 145.83 percent of total billed charges CHANGE OF CYSTOSTOMY TUBE; SIMPLE 51705_1 CDM 360 RC 51705 HCPCS outpatient 153.51 115.13 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 138.16 90 999999999 119.74 145.83 percent of total billed charges CHANGE OF CYSTOSTOMY TUBE; SIMPLE 51705_1 CDM 360 RC 51705 HCPCS outpatient 153.51 115.13 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 145.83 95 999999999 119.74 145.83 percent of total billed charges CHANGE OF CYSTOSTOMY TUBE; SIMPLE 51705_1 CDM 360 RC 51705 HCPCS outpatient 153.51 115.13 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 145.83 95 999999999 119.74 145.83 percent of total billed charges CHANGE OF CYSTOSTOMY TUBE; SIMPLE 51705_1 CDM 360 RC 51705 HCPCS outpatient 153.51 115.13 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 136.62 89 999999999 119.74 145.83 percent of total billed charges CHANGE OF CYSTOSTOMY TUBE; SIMPLE 51705_1 CDM 360 RC 51705 HCPCS outpatient 153.51 115.13 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 135.09 88 999999999 119.74 145.83 percent of total billed charges CHANGE OF CYSTOSTOMY TUBE; SIMPLE 51705_1 CDM 360 RC 51705 HCPCS outpatient 153.51 115.13 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 136.62 89 999999999 119.74 145.83 percent of total billed charges "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 51798_1 CDM 761 RC 51798 HCPCS outpatient 32.34 24.26 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 29.11 999999999 25.23 30.72 case rate "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 51798_1 CDM 761 RC 51798 HCPCS outpatient 32.34 24.26 AETNA MCR ADV AETNA MCR ADV 25.23 78 999999999 25.23 30.72 percent of total billed charges "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 51798_1 CDM 761 RC 51798 HCPCS outpatient 32.34 24.26 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 28.32 87.57 999999999 25.23 30.72 percent of total billed charges "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 51798_1 CDM 761 RC 51798 HCPCS outpatient 32.34 24.26 COORDINATED CARE MCAID COORDINATED CARE MCAID 27.51 85.07 999999999 25.23 30.72 percent of total billed charges "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 51798_1 CDM 761 RC 51798 HCPCS outpatient 32.34 24.26 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 27.51 85.07 999999999 25.23 30.72 percent of total billed charges "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 51798_1 CDM 761 RC 51798 HCPCS outpatient 32.34 24.26 MOLINA MCAID MOLINA MCAID 26.97 83.4 999999999 25.23 30.72 percent of total billed charges "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 51798_1 CDM 761 RC 51798 HCPCS outpatient 32.34 24.26 MOLINA MCR ADV MOLINA MCR ADV 28.78 89 999999999 25.23 30.72 percent of total billed charges "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 51798_1 CDM 761 RC 51798 HCPCS outpatient 32.34 24.26 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 28.78 89 999999999 25.23 30.72 percent of total billed charges "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 51798_1 CDM 761 RC 51798 HCPCS outpatient 32.34 24.26 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 28.78 89 999999999 25.23 30.72 percent of total billed charges "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 51798_1 CDM 761 RC 51798 HCPCS outpatient 32.34 24.26 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 29.11 90 999999999 25.23 30.72 percent of total billed charges "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 51798_1 CDM 761 RC 51798 HCPCS outpatient 32.34 24.26 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 30.72 95 999999999 25.23 30.72 percent of total billed charges "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 51798_1 CDM 761 RC 51798 HCPCS outpatient 32.34 24.26 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 30.72 95 999999999 25.23 30.72 percent of total billed charges "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 51798_1 CDM 761 RC 51798 HCPCS outpatient 32.34 24.26 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 28.78 89 999999999 25.23 30.72 percent of total billed charges "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 51798_1 CDM 761 RC 51798 HCPCS outpatient 32.34 24.26 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 28.46 88 999999999 25.23 30.72 percent of total billed charges "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 51798_1 CDM 761 RC 51798 HCPCS outpatient 32.34 24.26 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 28.78 89 999999999 25.23 30.72 percent of total billed charges "GROUND MILEAGE, PER STATUTE MILE" 540A042501_1 CDM 540 RC A0425 HCPCS outpatient 20 15 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 18 90 999999999 15.6 19 percent of total billed charges "GROUND MILEAGE, PER STATUTE MILE" 540A042501_1 CDM 540 RC A0425 HCPCS outpatient 20 15 AETNA MCR ADV AETNA MCR ADV 15.6 78 999999999 15.6 19 percent of total billed charges "GROUND MILEAGE, PER STATUTE MILE" 540A042501_1 CDM 540 RC A0425 HCPCS outpatient 20 15 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 17.51 87.57 999999999 15.6 19 percent of total billed charges "GROUND MILEAGE, PER STATUTE MILE" 540A042501_1 CDM 540 RC A0425 HCPCS outpatient 20 15 COORDINATED CARE MCAID COORDINATED CARE MCAID 17.01 85.07 999999999 15.6 19 percent of total billed charges "GROUND MILEAGE, PER STATUTE MILE" 540A042501_1 CDM 540 RC A0425 HCPCS outpatient 20 15 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 17.01 85.07 999999999 15.6 19 percent of total billed charges "GROUND MILEAGE, PER STATUTE MILE" 540A042501_1 CDM 540 RC A0425 HCPCS outpatient 20 15 MOLINA MCAID MOLINA MCAID 16.68 83.4 999999999 15.6 19 percent of total billed charges "GROUND MILEAGE, PER STATUTE MILE" 540A042501_1 CDM 540 RC A0425 HCPCS outpatient 20 15 MOLINA MCR ADV MOLINA MCR ADV 17.8 89 999999999 15.6 19 percent of total billed charges "GROUND MILEAGE, PER STATUTE MILE" 540A042501_1 CDM 540 RC A0425 HCPCS outpatient 20 15 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "GROUND MILEAGE, PER STATUTE MILE" 540A042501_1 CDM 540 RC A0425 HCPCS outpatient 20 15 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "GROUND MILEAGE, PER STATUTE MILE" 540A042501_1 CDM 540 RC A0425 HCPCS outpatient 20 15 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 18 90 999999999 15.6 19 percent of total billed charges "GROUND MILEAGE, PER STATUTE MILE" 540A042501_1 CDM 540 RC A0425 HCPCS outpatient 20 15 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 19 95 999999999 15.6 19 percent of total billed charges "GROUND MILEAGE, PER STATUTE MILE" 540A042501_1 CDM 540 RC A0425 HCPCS outpatient 20 15 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 19 95 999999999 15.6 19 percent of total billed charges "GROUND MILEAGE, PER STATUTE MILE" 540A042501_1 CDM 540 RC A0425 HCPCS outpatient 20 15 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 17.8 89 999999999 15.6 19 percent of total billed charges "GROUND MILEAGE, PER STATUTE MILE" 540A042501_1 CDM 540 RC A0425 HCPCS outpatient 20 15 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 17.6 88 999999999 15.6 19 percent of total billed charges "GROUND MILEAGE, PER STATUTE MILE" 540A042501_1 CDM 540 RC A0425 HCPCS outpatient 20 15 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, EMERGENCY TRANSPORT, LEVEL 1 (ALS 1 - EMERGENCY)" 540A042701_1 CDM 540 RC A0427 HCPCS outpatient 990 742.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 891 90 999999999 772.2 940.5 percent of total billed charges "AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, EMERGENCY TRANSPORT, LEVEL 1 (ALS 1 - EMERGENCY)" 540A042701_1 CDM 540 RC A0427 HCPCS outpatient 990 742.5 AETNA MCR ADV AETNA MCR ADV 772.2 78 999999999 772.2 940.5 percent of total billed charges "AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, EMERGENCY TRANSPORT, LEVEL 1 (ALS 1 - EMERGENCY)" 540A042701_1 CDM 540 RC A0427 HCPCS outpatient 990 742.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 866.94 87.57 999999999 772.2 940.5 percent of total billed charges "AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, EMERGENCY TRANSPORT, LEVEL 1 (ALS 1 - EMERGENCY)" 540A042701_1 CDM 540 RC A0427 HCPCS outpatient 990 742.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 842.19 85.07 999999999 772.2 940.5 percent of total billed charges "AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, EMERGENCY TRANSPORT, LEVEL 1 (ALS 1 - EMERGENCY)" 540A042701_1 CDM 540 RC A0427 HCPCS outpatient 990 742.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 842.19 85.07 999999999 772.2 940.5 percent of total billed charges "AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, EMERGENCY TRANSPORT, LEVEL 1 (ALS 1 - EMERGENCY)" 540A042701_1 CDM 540 RC A0427 HCPCS outpatient 990 742.5 MOLINA MCAID MOLINA MCAID 825.66 83.4 999999999 772.2 940.5 percent of total billed charges "AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, EMERGENCY TRANSPORT, LEVEL 1 (ALS 1 - EMERGENCY)" 540A042701_1 CDM 540 RC A0427 HCPCS outpatient 990 742.5 MOLINA MCR ADV MOLINA MCR ADV 881.1 89 999999999 772.2 940.5 percent of total billed charges "AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, EMERGENCY TRANSPORT, LEVEL 1 (ALS 1 - EMERGENCY)" 540A042701_1 CDM 540 RC A0427 HCPCS outpatient 990 742.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 881.1 89 999999999 772.2 940.5 percent of total billed charges "AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, EMERGENCY TRANSPORT, LEVEL 1 (ALS 1 - EMERGENCY)" 540A042701_1 CDM 540 RC A0427 HCPCS outpatient 990 742.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 881.1 89 999999999 772.2 940.5 percent of total billed charges "AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, EMERGENCY TRANSPORT, LEVEL 1 (ALS 1 - EMERGENCY)" 540A042701_1 CDM 540 RC A0427 HCPCS outpatient 990 742.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 891 90 999999999 772.2 940.5 percent of total billed charges "AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, EMERGENCY TRANSPORT, LEVEL 1 (ALS 1 - EMERGENCY)" 540A042701_1 CDM 540 RC A0427 HCPCS outpatient 990 742.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 940.5 95 999999999 772.2 940.5 percent of total billed charges "AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, EMERGENCY TRANSPORT, LEVEL 1 (ALS 1 - EMERGENCY)" 540A042701_1 CDM 540 RC A0427 HCPCS outpatient 990 742.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 940.5 95 999999999 772.2 940.5 percent of total billed charges "AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, EMERGENCY TRANSPORT, LEVEL 1 (ALS 1 - EMERGENCY)" 540A042701_1 CDM 540 RC A0427 HCPCS outpatient 990 742.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 881.1 89 999999999 772.2 940.5 percent of total billed charges "AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, EMERGENCY TRANSPORT, LEVEL 1 (ALS 1 - EMERGENCY)" 540A042701_1 CDM 540 RC A0427 HCPCS outpatient 990 742.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 871.2 88 999999999 772.2 940.5 percent of total billed charges "AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, EMERGENCY TRANSPORT, LEVEL 1 (ALS 1 - EMERGENCY)" 540A042701_1 CDM 540 RC A0427 HCPCS outpatient 990 742.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 881.1 89 999999999 772.2 940.5 percent of total billed charges "AMBULANCE SERVICE, BASIC LIFE SUPPORT, EMERGENCY TRANSPORT (BLS-EMERGENCY)" 540A042901_1 CDM 540 RC A0429 HCPCS outpatient 729 546.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 656.1 90 999999999 568.62 692.55 percent of total billed charges "AMBULANCE SERVICE, BASIC LIFE SUPPORT, EMERGENCY TRANSPORT (BLS-EMERGENCY)" 540A042901_1 CDM 540 RC A0429 HCPCS outpatient 729 546.75 AETNA MCR ADV AETNA MCR ADV 568.62 78 999999999 568.62 692.55 percent of total billed charges "AMBULANCE SERVICE, BASIC LIFE SUPPORT, EMERGENCY TRANSPORT (BLS-EMERGENCY)" 540A042901_1 CDM 540 RC A0429 HCPCS outpatient 729 546.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 638.39 87.57 999999999 568.62 692.55 percent of total billed charges "AMBULANCE SERVICE, BASIC LIFE SUPPORT, EMERGENCY TRANSPORT (BLS-EMERGENCY)" 540A042901_1 CDM 540 RC A0429 HCPCS outpatient 729 546.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 620.16 85.07 999999999 568.62 692.55 percent of total billed charges "AMBULANCE SERVICE, BASIC LIFE SUPPORT, EMERGENCY TRANSPORT (BLS-EMERGENCY)" 540A042901_1 CDM 540 RC A0429 HCPCS outpatient 729 546.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 620.16 85.07 999999999 568.62 692.55 percent of total billed charges "AMBULANCE SERVICE, BASIC LIFE SUPPORT, EMERGENCY TRANSPORT (BLS-EMERGENCY)" 540A042901_1 CDM 540 RC A0429 HCPCS outpatient 729 546.75 MOLINA MCAID MOLINA MCAID 607.99 83.4 999999999 568.62 692.55 percent of total billed charges "AMBULANCE SERVICE, BASIC LIFE SUPPORT, EMERGENCY TRANSPORT (BLS-EMERGENCY)" 540A042901_1 CDM 540 RC A0429 HCPCS outpatient 729 546.75 MOLINA MCR ADV MOLINA MCR ADV 648.81 89 999999999 568.62 692.55 percent of total billed charges "AMBULANCE SERVICE, BASIC LIFE SUPPORT, EMERGENCY TRANSPORT (BLS-EMERGENCY)" 540A042901_1 CDM 540 RC A0429 HCPCS outpatient 729 546.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 648.81 89 999999999 568.62 692.55 percent of total billed charges "AMBULANCE SERVICE, BASIC LIFE SUPPORT, EMERGENCY TRANSPORT (BLS-EMERGENCY)" 540A042901_1 CDM 540 RC A0429 HCPCS outpatient 729 546.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 648.81 89 999999999 568.62 692.55 percent of total billed charges "AMBULANCE SERVICE, BASIC LIFE SUPPORT, EMERGENCY TRANSPORT (BLS-EMERGENCY)" 540A042901_1 CDM 540 RC A0429 HCPCS outpatient 729 546.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 656.1 90 999999999 568.62 692.55 percent of total billed charges "AMBULANCE SERVICE, BASIC LIFE SUPPORT, EMERGENCY TRANSPORT (BLS-EMERGENCY)" 540A042901_1 CDM 540 RC A0429 HCPCS outpatient 729 546.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 692.55 95 999999999 568.62 692.55 percent of total billed charges "AMBULANCE SERVICE, BASIC LIFE SUPPORT, EMERGENCY TRANSPORT (BLS-EMERGENCY)" 540A042901_1 CDM 540 RC A0429 HCPCS outpatient 729 546.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 692.55 95 999999999 568.62 692.55 percent of total billed charges "AMBULANCE SERVICE, BASIC LIFE SUPPORT, EMERGENCY TRANSPORT (BLS-EMERGENCY)" 540A042901_1 CDM 540 RC A0429 HCPCS outpatient 729 546.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 648.81 89 999999999 568.62 692.55 percent of total billed charges "AMBULANCE SERVICE, BASIC LIFE SUPPORT, EMERGENCY TRANSPORT (BLS-EMERGENCY)" 540A042901_1 CDM 540 RC A0429 HCPCS outpatient 729 546.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 641.52 88 999999999 568.62 692.55 percent of total billed charges "AMBULANCE SERVICE, BASIC LIFE SUPPORT, EMERGENCY TRANSPORT (BLS-EMERGENCY)" 540A042901_1 CDM 540 RC A0429 HCPCS outpatient 729 546.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 648.81 89 999999999 568.62 692.55 percent of total billed charges "CAUTERY OF CERVIX; CRYOCAUTERY, INITIAL OR REPEAT" 57511_3 CDM 360 RC 57511 HCPCS outpatient 416 312 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 374.4 999999999 324.48 395.2 case rate "CAUTERY OF CERVIX; CRYOCAUTERY, INITIAL OR REPEAT" 57511_3 CDM 360 RC 57511 HCPCS outpatient 416 312 AETNA MCR ADV AETNA MCR ADV 324.48 78 999999999 324.48 395.2 percent of total billed charges "CAUTERY OF CERVIX; CRYOCAUTERY, INITIAL OR REPEAT" 57511_3 CDM 360 RC 57511 HCPCS outpatient 416 312 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 364.29 87.57 999999999 324.48 395.2 percent of total billed charges "CAUTERY OF CERVIX; CRYOCAUTERY, INITIAL OR REPEAT" 57511_3 CDM 360 RC 57511 HCPCS outpatient 416 312 COORDINATED CARE MCAID COORDINATED CARE MCAID 353.89 85.07 999999999 324.48 395.2 percent of total billed charges "CAUTERY OF CERVIX; CRYOCAUTERY, INITIAL OR REPEAT" 57511_3 CDM 360 RC 57511 HCPCS outpatient 416 312 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 353.89 85.07 999999999 324.48 395.2 percent of total billed charges "CAUTERY OF CERVIX; CRYOCAUTERY, INITIAL OR REPEAT" 57511_3 CDM 360 RC 57511 HCPCS outpatient 416 312 MOLINA MCAID MOLINA MCAID 346.94 83.4 999999999 324.48 395.2 percent of total billed charges "CAUTERY OF CERVIX; CRYOCAUTERY, INITIAL OR REPEAT" 57511_3 CDM 360 RC 57511 HCPCS outpatient 416 312 MOLINA MCR ADV MOLINA MCR ADV 370.24 89 999999999 324.48 395.2 percent of total billed charges "CAUTERY OF CERVIX; CRYOCAUTERY, INITIAL OR REPEAT" 57511_3 CDM 360 RC 57511 HCPCS outpatient 416 312 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 370.24 89 999999999 324.48 395.2 percent of total billed charges "CAUTERY OF CERVIX; CRYOCAUTERY, INITIAL OR REPEAT" 57511_3 CDM 360 RC 57511 HCPCS outpatient 416 312 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 370.24 89 999999999 324.48 395.2 percent of total billed charges "CAUTERY OF CERVIX; CRYOCAUTERY, INITIAL OR REPEAT" 57511_3 CDM 360 RC 57511 HCPCS outpatient 416 312 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 374.4 90 999999999 324.48 395.2 percent of total billed charges "CAUTERY OF CERVIX; CRYOCAUTERY, INITIAL OR REPEAT" 57511_3 CDM 360 RC 57511 HCPCS outpatient 416 312 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 395.2 95 999999999 324.48 395.2 percent of total billed charges "CAUTERY OF CERVIX; CRYOCAUTERY, INITIAL OR REPEAT" 57511_3 CDM 360 RC 57511 HCPCS outpatient 416 312 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 395.2 95 999999999 324.48 395.2 percent of total billed charges "CAUTERY OF CERVIX; CRYOCAUTERY, INITIAL OR REPEAT" 57511_3 CDM 360 RC 57511 HCPCS outpatient 416 312 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 370.24 89 999999999 324.48 395.2 percent of total billed charges "CAUTERY OF CERVIX; CRYOCAUTERY, INITIAL OR REPEAT" 57511_3 CDM 360 RC 57511 HCPCS outpatient 416 312 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 366.08 88 999999999 324.48 395.2 percent of total billed charges "CAUTERY OF CERVIX; CRYOCAUTERY, INITIAL OR REPEAT" 57511_3 CDM 360 RC 57511 HCPCS outpatient 416 312 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 370.24 89 999999999 324.48 395.2 percent of total billed charges "ENDOMETRIAL SAMPLING (BIOPSY) WITH OR WITHOUT ENDOCERVICAL SAMPLING (BIOPSY), WITHOUT CERVICAL DILATION, ANY METHOD (SEPARATE PROCEDURE)" 58100_3 CDM 360 RC 58100 HCPCS outpatient 210 157.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 189 999999999 163.8 199.5 case rate "ENDOMETRIAL SAMPLING (BIOPSY) WITH OR WITHOUT ENDOCERVICAL SAMPLING (BIOPSY), WITHOUT CERVICAL DILATION, ANY METHOD (SEPARATE PROCEDURE)" 58100_3 CDM 360 RC 58100 HCPCS outpatient 210 157.5 AETNA MCR ADV AETNA MCR ADV 163.8 78 999999999 163.8 199.5 percent of total billed charges "ENDOMETRIAL SAMPLING (BIOPSY) WITH OR WITHOUT ENDOCERVICAL SAMPLING (BIOPSY), WITHOUT CERVICAL DILATION, ANY METHOD (SEPARATE PROCEDURE)" 58100_3 CDM 360 RC 58100 HCPCS outpatient 210 157.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 183.9 87.57 999999999 163.8 199.5 percent of total billed charges "ENDOMETRIAL SAMPLING (BIOPSY) WITH OR WITHOUT ENDOCERVICAL SAMPLING (BIOPSY), WITHOUT CERVICAL DILATION, ANY METHOD (SEPARATE PROCEDURE)" 58100_3 CDM 360 RC 58100 HCPCS outpatient 210 157.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 178.65 85.07 999999999 163.8 199.5 percent of total billed charges "ENDOMETRIAL SAMPLING (BIOPSY) WITH OR WITHOUT ENDOCERVICAL SAMPLING (BIOPSY), WITHOUT CERVICAL DILATION, ANY METHOD (SEPARATE PROCEDURE)" 58100_3 CDM 360 RC 58100 HCPCS outpatient 210 157.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 178.65 85.07 999999999 163.8 199.5 percent of total billed charges "ENDOMETRIAL SAMPLING (BIOPSY) WITH OR WITHOUT ENDOCERVICAL SAMPLING (BIOPSY), WITHOUT CERVICAL DILATION, ANY METHOD (SEPARATE PROCEDURE)" 58100_3 CDM 360 RC 58100 HCPCS outpatient 210 157.5 MOLINA MCAID MOLINA MCAID 175.14 83.4 999999999 163.8 199.5 percent of total billed charges "ENDOMETRIAL SAMPLING (BIOPSY) WITH OR WITHOUT ENDOCERVICAL SAMPLING (BIOPSY), WITHOUT CERVICAL DILATION, ANY METHOD (SEPARATE PROCEDURE)" 58100_3 CDM 360 RC 58100 HCPCS outpatient 210 157.5 MOLINA MCR ADV MOLINA MCR ADV 186.9 89 999999999 163.8 199.5 percent of total billed charges "ENDOMETRIAL SAMPLING (BIOPSY) WITH OR WITHOUT ENDOCERVICAL SAMPLING (BIOPSY), WITHOUT CERVICAL DILATION, ANY METHOD (SEPARATE PROCEDURE)" 58100_3 CDM 360 RC 58100 HCPCS outpatient 210 157.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 186.9 89 999999999 163.8 199.5 percent of total billed charges "ENDOMETRIAL SAMPLING (BIOPSY) WITH OR WITHOUT ENDOCERVICAL SAMPLING (BIOPSY), WITHOUT CERVICAL DILATION, ANY METHOD (SEPARATE PROCEDURE)" 58100_3 CDM 360 RC 58100 HCPCS outpatient 210 157.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 186.9 89 999999999 163.8 199.5 percent of total billed charges "ENDOMETRIAL SAMPLING (BIOPSY) WITH OR WITHOUT ENDOCERVICAL SAMPLING (BIOPSY), WITHOUT CERVICAL DILATION, ANY METHOD (SEPARATE PROCEDURE)" 58100_3 CDM 360 RC 58100 HCPCS outpatient 210 157.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 189 90 999999999 163.8 199.5 percent of total billed charges "ENDOMETRIAL SAMPLING (BIOPSY) WITH OR WITHOUT ENDOCERVICAL SAMPLING (BIOPSY), WITHOUT CERVICAL DILATION, ANY METHOD (SEPARATE PROCEDURE)" 58100_3 CDM 360 RC 58100 HCPCS outpatient 210 157.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 199.5 95 999999999 163.8 199.5 percent of total billed charges "ENDOMETRIAL SAMPLING (BIOPSY) WITH OR WITHOUT ENDOCERVICAL SAMPLING (BIOPSY), WITHOUT CERVICAL DILATION, ANY METHOD (SEPARATE PROCEDURE)" 58100_3 CDM 360 RC 58100 HCPCS outpatient 210 157.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 199.5 95 999999999 163.8 199.5 percent of total billed charges "ENDOMETRIAL SAMPLING (BIOPSY) WITH OR WITHOUT ENDOCERVICAL SAMPLING (BIOPSY), WITHOUT CERVICAL DILATION, ANY METHOD (SEPARATE PROCEDURE)" 58100_3 CDM 360 RC 58100 HCPCS outpatient 210 157.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 186.9 89 999999999 163.8 199.5 percent of total billed charges "ENDOMETRIAL SAMPLING (BIOPSY) WITH OR WITHOUT ENDOCERVICAL SAMPLING (BIOPSY), WITHOUT CERVICAL DILATION, ANY METHOD (SEPARATE PROCEDURE)" 58100_3 CDM 360 RC 58100 HCPCS outpatient 210 157.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 184.8 88 999999999 163.8 199.5 percent of total billed charges "ENDOMETRIAL SAMPLING (BIOPSY) WITH OR WITHOUT ENDOCERVICAL SAMPLING (BIOPSY), WITHOUT CERVICAL DILATION, ANY METHOD (SEPARATE PROCEDURE)" 58100_3 CDM 360 RC 58100 HCPCS outpatient 210 157.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 186.9 89 999999999 163.8 199.5 percent of total billed charges REMOVAL OF INTRAUTERINE DEVICE (IUD) 58301_3 CDM 360 RC 58301 HCPCS outpatient 130 97.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 117 999999999 101.4 123.5 case rate REMOVAL OF INTRAUTERINE DEVICE (IUD) 58301_3 CDM 360 RC 58301 HCPCS outpatient 130 97.5 AETNA MCR ADV AETNA MCR ADV 101.4 78 999999999 101.4 123.5 percent of total billed charges REMOVAL OF INTRAUTERINE DEVICE (IUD) 58301_3 CDM 360 RC 58301 HCPCS outpatient 130 97.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 113.84 87.57 999999999 101.4 123.5 percent of total billed charges REMOVAL OF INTRAUTERINE DEVICE (IUD) 58301_3 CDM 360 RC 58301 HCPCS outpatient 130 97.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 110.59 85.07 999999999 101.4 123.5 percent of total billed charges REMOVAL OF INTRAUTERINE DEVICE (IUD) 58301_3 CDM 360 RC 58301 HCPCS outpatient 130 97.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 110.59 85.07 999999999 101.4 123.5 percent of total billed charges REMOVAL OF INTRAUTERINE DEVICE (IUD) 58301_3 CDM 360 RC 58301 HCPCS outpatient 130 97.5 MOLINA MCAID MOLINA MCAID 108.42 83.4 999999999 101.4 123.5 percent of total billed charges REMOVAL OF INTRAUTERINE DEVICE (IUD) 58301_3 CDM 360 RC 58301 HCPCS outpatient 130 97.5 MOLINA MCR ADV MOLINA MCR ADV 115.7 89 999999999 101.4 123.5 percent of total billed charges REMOVAL OF INTRAUTERINE DEVICE (IUD) 58301_3 CDM 360 RC 58301 HCPCS outpatient 130 97.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 115.7 89 999999999 101.4 123.5 percent of total billed charges REMOVAL OF INTRAUTERINE DEVICE (IUD) 58301_3 CDM 360 RC 58301 HCPCS outpatient 130 97.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 115.7 89 999999999 101.4 123.5 percent of total billed charges REMOVAL OF INTRAUTERINE DEVICE (IUD) 58301_3 CDM 360 RC 58301 HCPCS outpatient 130 97.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 117 90 999999999 101.4 123.5 percent of total billed charges REMOVAL OF INTRAUTERINE DEVICE (IUD) 58301_3 CDM 360 RC 58301 HCPCS outpatient 130 97.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 123.5 95 999999999 101.4 123.5 percent of total billed charges REMOVAL OF INTRAUTERINE DEVICE (IUD) 58301_3 CDM 360 RC 58301 HCPCS outpatient 130 97.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 123.5 95 999999999 101.4 123.5 percent of total billed charges REMOVAL OF INTRAUTERINE DEVICE (IUD) 58301_3 CDM 360 RC 58301 HCPCS outpatient 130 97.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 115.7 89 999999999 101.4 123.5 percent of total billed charges REMOVAL OF INTRAUTERINE DEVICE (IUD) 58301_3 CDM 360 RC 58301 HCPCS outpatient 130 97.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 114.4 88 999999999 101.4 123.5 percent of total billed charges REMOVAL OF INTRAUTERINE DEVICE (IUD) 58301_3 CDM 360 RC 58301 HCPCS outpatient 130 97.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 115.7 89 999999999 101.4 123.5 percent of total billed charges VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS) 59409_1 CDM 360 RC 59409 HCPCS outpatient 2372.67 1779.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 2135.4 999999999 1850.68 2254.04 case rate VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS) 59409_1 CDM 360 RC 59409 HCPCS outpatient 2372.67 1779.5 AETNA MCR ADV AETNA MCR ADV 1850.68 78 999999999 1850.68 2254.04 percent of total billed charges VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS) 59409_1 CDM 360 RC 59409 HCPCS outpatient 2372.67 1779.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 2077.75 87.57 999999999 1850.68 2254.04 percent of total billed charges VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS) 59409_1 CDM 360 RC 59409 HCPCS outpatient 2372.67 1779.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 2018.43 85.07 999999999 1850.68 2254.04 percent of total billed charges VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS) 59409_1 CDM 360 RC 59409 HCPCS outpatient 2372.67 1779.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 2018.43 85.07 999999999 1850.68 2254.04 percent of total billed charges VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS) 59409_1 CDM 360 RC 59409 HCPCS outpatient 2372.67 1779.5 MOLINA MCAID MOLINA MCAID 1978.81 83.4 999999999 1850.68 2254.04 percent of total billed charges VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS) 59409_1 CDM 360 RC 59409 HCPCS outpatient 2372.67 1779.5 MOLINA MCR ADV MOLINA MCR ADV 2111.68 89 999999999 1850.68 2254.04 percent of total billed charges VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS) 59409_1 CDM 360 RC 59409 HCPCS outpatient 2372.67 1779.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 2111.68 89 999999999 1850.68 2254.04 percent of total billed charges VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS) 59409_1 CDM 360 RC 59409 HCPCS outpatient 2372.67 1779.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 2111.68 89 999999999 1850.68 2254.04 percent of total billed charges VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS) 59409_1 CDM 360 RC 59409 HCPCS outpatient 2372.67 1779.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 2135.4 90 999999999 1850.68 2254.04 percent of total billed charges VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS) 59409_1 CDM 360 RC 59409 HCPCS outpatient 2372.67 1779.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 2254.04 95 999999999 1850.68 2254.04 percent of total billed charges VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS) 59409_1 CDM 360 RC 59409 HCPCS outpatient 2372.67 1779.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 2254.04 95 999999999 1850.68 2254.04 percent of total billed charges VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS) 59409_1 CDM 360 RC 59409 HCPCS outpatient 2372.67 1779.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 2111.68 89 999999999 1850.68 2254.04 percent of total billed charges VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS) 59409_1 CDM 360 RC 59409 HCPCS outpatient 2372.67 1779.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 2087.95 88 999999999 1850.68 2254.04 percent of total billed charges VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS) 59409_1 CDM 360 RC 59409 HCPCS outpatient 2372.67 1779.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 2111.68 89 999999999 1850.68 2254.04 percent of total billed charges "MAGNETIC RESONANCE IMAGING, BRAIN, FUNCTIONAL MRI; INCLUDING TEST SELECTION AND ADMINISTRATION OF REPETITIVE BODY PART MOVEMENT AND/OR VISUAL STIMULATION, NOT REQUIRING PHYSICIAN OR PSYCHOLOGIST ADMINISTRATION" 6117055401_1 CDM 611 RC 70554 HCPCS outpatient 2672 2004 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 2404.8 90 999999999 2084.16 2538.4 percent of total billed charges "MAGNETIC RESONANCE IMAGING, BRAIN, FUNCTIONAL MRI; INCLUDING TEST SELECTION AND ADMINISTRATION OF REPETITIVE BODY PART MOVEMENT AND/OR VISUAL STIMULATION, NOT REQUIRING PHYSICIAN OR PSYCHOLOGIST ADMINISTRATION" 6117055401_1 CDM 611 RC 70554 HCPCS outpatient 2672 2004 AETNA MCR ADV AETNA MCR ADV 2084.16 78 999999999 2084.16 2538.4 percent of total billed charges "MAGNETIC RESONANCE IMAGING, BRAIN, FUNCTIONAL MRI; INCLUDING TEST SELECTION AND ADMINISTRATION OF REPETITIVE BODY PART MOVEMENT AND/OR VISUAL STIMULATION, NOT REQUIRING PHYSICIAN OR PSYCHOLOGIST ADMINISTRATION" 6117055401_1 CDM 611 RC 70554 HCPCS outpatient 2672 2004 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 2339.87 87.57 999999999 2084.16 2538.4 percent of total billed charges "MAGNETIC RESONANCE IMAGING, BRAIN, FUNCTIONAL MRI; INCLUDING TEST SELECTION AND ADMINISTRATION OF REPETITIVE BODY PART MOVEMENT AND/OR VISUAL STIMULATION, NOT REQUIRING PHYSICIAN OR PSYCHOLOGIST ADMINISTRATION" 6117055401_1 CDM 611 RC 70554 HCPCS outpatient 2672 2004 COORDINATED CARE MCAID COORDINATED CARE MCAID 2273.07 85.07 999999999 2084.16 2538.4 percent of total billed charges "MAGNETIC RESONANCE IMAGING, BRAIN, FUNCTIONAL MRI; INCLUDING TEST SELECTION AND ADMINISTRATION OF REPETITIVE BODY PART MOVEMENT AND/OR VISUAL STIMULATION, NOT REQUIRING PHYSICIAN OR PSYCHOLOGIST ADMINISTRATION" 6117055401_1 CDM 611 RC 70554 HCPCS outpatient 2672 2004 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 2273.07 85.07 999999999 2084.16 2538.4 percent of total billed charges "MAGNETIC RESONANCE IMAGING, BRAIN, FUNCTIONAL MRI; INCLUDING TEST SELECTION AND ADMINISTRATION OF REPETITIVE BODY PART MOVEMENT AND/OR VISUAL STIMULATION, NOT REQUIRING PHYSICIAN OR PSYCHOLOGIST ADMINISTRATION" 6117055401_1 CDM 611 RC 70554 HCPCS outpatient 2672 2004 MOLINA MCAID MOLINA MCAID 2228.45 83.4 999999999 2084.16 2538.4 percent of total billed charges "MAGNETIC RESONANCE IMAGING, BRAIN, FUNCTIONAL MRI; INCLUDING TEST SELECTION AND ADMINISTRATION OF REPETITIVE BODY PART MOVEMENT AND/OR VISUAL STIMULATION, NOT REQUIRING PHYSICIAN OR PSYCHOLOGIST ADMINISTRATION" 6117055401_1 CDM 611 RC 70554 HCPCS outpatient 2672 2004 MOLINA MCR ADV MOLINA MCR ADV 2378.08 89 999999999 2084.16 2538.4 percent of total billed charges "MAGNETIC RESONANCE IMAGING, BRAIN, FUNCTIONAL MRI; INCLUDING TEST SELECTION AND ADMINISTRATION OF REPETITIVE BODY PART MOVEMENT AND/OR VISUAL STIMULATION, NOT REQUIRING PHYSICIAN OR PSYCHOLOGIST ADMINISTRATION" 6117055401_1 CDM 611 RC 70554 HCPCS outpatient 2672 2004 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 2378.08 89 999999999 2084.16 2538.4 percent of total billed charges "MAGNETIC RESONANCE IMAGING, BRAIN, FUNCTIONAL MRI; INCLUDING TEST SELECTION AND ADMINISTRATION OF REPETITIVE BODY PART MOVEMENT AND/OR VISUAL STIMULATION, NOT REQUIRING PHYSICIAN OR PSYCHOLOGIST ADMINISTRATION" 6117055401_1 CDM 611 RC 70554 HCPCS outpatient 2672 2004 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 2378.08 89 999999999 2084.16 2538.4 percent of total billed charges "MAGNETIC RESONANCE IMAGING, BRAIN, FUNCTIONAL MRI; INCLUDING TEST SELECTION AND ADMINISTRATION OF REPETITIVE BODY PART MOVEMENT AND/OR VISUAL STIMULATION, NOT REQUIRING PHYSICIAN OR PSYCHOLOGIST ADMINISTRATION" 6117055401_1 CDM 611 RC 70554 HCPCS outpatient 2672 2004 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 2404.8 90 999999999 2084.16 2538.4 percent of total billed charges "MAGNETIC RESONANCE IMAGING, BRAIN, FUNCTIONAL MRI; INCLUDING TEST SELECTION AND ADMINISTRATION OF REPETITIVE BODY PART MOVEMENT AND/OR VISUAL STIMULATION, NOT REQUIRING PHYSICIAN OR PSYCHOLOGIST ADMINISTRATION" 6117055401_1 CDM 611 RC 70554 HCPCS outpatient 2672 2004 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 2538.4 95 999999999 2084.16 2538.4 percent of total billed charges "MAGNETIC RESONANCE IMAGING, BRAIN, FUNCTIONAL MRI; INCLUDING TEST SELECTION AND ADMINISTRATION OF REPETITIVE BODY PART MOVEMENT AND/OR VISUAL STIMULATION, NOT REQUIRING PHYSICIAN OR PSYCHOLOGIST ADMINISTRATION" 6117055401_1 CDM 611 RC 70554 HCPCS outpatient 2672 2004 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 2538.4 95 999999999 2084.16 2538.4 percent of total billed charges "MAGNETIC RESONANCE IMAGING, BRAIN, FUNCTIONAL MRI; INCLUDING TEST SELECTION AND ADMINISTRATION OF REPETITIVE BODY PART MOVEMENT AND/OR VISUAL STIMULATION, NOT REQUIRING PHYSICIAN OR PSYCHOLOGIST ADMINISTRATION" 6117055401_1 CDM 611 RC 70554 HCPCS outpatient 2672 2004 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 2378.08 89 999999999 2084.16 2538.4 percent of total billed charges "MAGNETIC RESONANCE IMAGING, BRAIN, FUNCTIONAL MRI; INCLUDING TEST SELECTION AND ADMINISTRATION OF REPETITIVE BODY PART MOVEMENT AND/OR VISUAL STIMULATION, NOT REQUIRING PHYSICIAN OR PSYCHOLOGIST ADMINISTRATION" 6117055401_1 CDM 611 RC 70554 HCPCS outpatient 2672 2004 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 2351.36 88 999999999 2084.16 2538.4 percent of total billed charges "MAGNETIC RESONANCE IMAGING, BRAIN, FUNCTIONAL MRI; INCLUDING TEST SELECTION AND ADMINISTRATION OF REPETITIVE BODY PART MOVEMENT AND/OR VISUAL STIMULATION, NOT REQUIRING PHYSICIAN OR PSYCHOLOGIST ADMINISTRATION" 6117055401_1 CDM 611 RC 70554 HCPCS outpatient 2672 2004 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 2378.08 89 999999999 2084.16 2538.4 percent of total billed charges "SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC" 62270_1 CDM 361 RC 62270 HCPCS outpatient 184.23 138.17 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 165.81 999999999 143.7 175.02 case rate "SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC" 62270_1 CDM 361 RC 62270 HCPCS outpatient 184.23 138.17 AETNA MCR ADV AETNA MCR ADV 143.7 78 999999999 143.7 175.02 percent of total billed charges "SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC" 62270_1 CDM 361 RC 62270 HCPCS outpatient 184.23 138.17 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 161.33 87.57 999999999 143.7 175.02 percent of total billed charges "SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC" 62270_1 CDM 361 RC 62270 HCPCS outpatient 184.23 138.17 COORDINATED CARE MCAID COORDINATED CARE MCAID 156.72 85.07 999999999 143.7 175.02 percent of total billed charges "SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC" 62270_1 CDM 361 RC 62270 HCPCS outpatient 184.23 138.17 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 156.72 85.07 999999999 143.7 175.02 percent of total billed charges "SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC" 62270_1 CDM 361 RC 62270 HCPCS outpatient 184.23 138.17 MOLINA MCAID MOLINA MCAID 153.65 83.4 999999999 143.7 175.02 percent of total billed charges "SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC" 62270_1 CDM 361 RC 62270 HCPCS outpatient 184.23 138.17 MOLINA MCR ADV MOLINA MCR ADV 163.96 89 999999999 143.7 175.02 percent of total billed charges "SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC" 62270_1 CDM 361 RC 62270 HCPCS outpatient 184.23 138.17 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 163.96 89 999999999 143.7 175.02 percent of total billed charges "SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC" 62270_1 CDM 361 RC 62270 HCPCS outpatient 184.23 138.17 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 163.96 89 999999999 143.7 175.02 percent of total billed charges "SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC" 62270_1 CDM 361 RC 62270 HCPCS outpatient 184.23 138.17 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 165.81 90 999999999 143.7 175.02 percent of total billed charges "SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC" 62270_1 CDM 361 RC 62270 HCPCS outpatient 184.23 138.17 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 175.02 95 999999999 143.7 175.02 percent of total billed charges "SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC" 62270_1 CDM 361 RC 62270 HCPCS outpatient 184.23 138.17 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 175.02 95 999999999 143.7 175.02 percent of total billed charges "SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC" 62270_1 CDM 361 RC 62270 HCPCS outpatient 184.23 138.17 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 163.96 89 999999999 143.7 175.02 percent of total billed charges "SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC" 62270_1 CDM 361 RC 62270 HCPCS outpatient 184.23 138.17 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 162.12 88 999999999 143.7 175.02 percent of total billed charges "SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC" 62270_1 CDM 361 RC 62270 HCPCS outpatient 184.23 138.17 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 163.96 89 999999999 143.7 175.02 percent of total billed charges "INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)" 62321_1 CDM 361 RC 62321 HCPCS outpatient 1215 911.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1093.5 999999999 947.7 1154.25 case rate "INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)" 62321_1 CDM 361 RC 62321 HCPCS outpatient 1215 911.25 AETNA MCR ADV AETNA MCR ADV 947.7 78 999999999 947.7 1154.25 percent of total billed charges "INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)" 62321_1 CDM 361 RC 62321 HCPCS outpatient 1215 911.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1063.98 87.57 999999999 947.7 1154.25 percent of total billed charges "INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)" 62321_1 CDM 361 RC 62321 HCPCS outpatient 1215 911.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 1033.6 85.07 999999999 947.7 1154.25 percent of total billed charges "INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)" 62321_1 CDM 361 RC 62321 HCPCS outpatient 1215 911.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1033.6 85.07 999999999 947.7 1154.25 percent of total billed charges "INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)" 62321_1 CDM 361 RC 62321 HCPCS outpatient 1215 911.25 MOLINA MCAID MOLINA MCAID 1013.31 83.4 999999999 947.7 1154.25 percent of total billed charges "INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)" 62321_1 CDM 361 RC 62321 HCPCS outpatient 1215 911.25 MOLINA MCR ADV MOLINA MCR ADV 1081.35 89 999999999 947.7 1154.25 percent of total billed charges "INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)" 62321_1 CDM 361 RC 62321 HCPCS outpatient 1215 911.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1081.35 89 999999999 947.7 1154.25 percent of total billed charges "INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)" 62321_1 CDM 361 RC 62321 HCPCS outpatient 1215 911.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1081.35 89 999999999 947.7 1154.25 percent of total billed charges "INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)" 62321_1 CDM 361 RC 62321 HCPCS outpatient 1215 911.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1093.5 90 999999999 947.7 1154.25 percent of total billed charges "INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)" 62321_1 CDM 361 RC 62321 HCPCS outpatient 1215 911.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1154.25 95 999999999 947.7 1154.25 percent of total billed charges "INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)" 62321_1 CDM 361 RC 62321 HCPCS outpatient 1215 911.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1154.25 95 999999999 947.7 1154.25 percent of total billed charges "INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)" 62321_1 CDM 361 RC 62321 HCPCS outpatient 1215 911.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1081.35 89 999999999 947.7 1154.25 percent of total billed charges "INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)" 62321_1 CDM 361 RC 62321 HCPCS outpatient 1215 911.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1069.2 88 999999999 947.7 1154.25 percent of total billed charges "INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)" 62321_1 CDM 361 RC 62321 HCPCS outpatient 1215 911.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1081.35 89 999999999 947.7 1154.25 percent of total billed charges "ADENOVIRUS VACCINE, TYPE 4, LIVE, FOR ORAL USE" 6369047601_1 CDM 636 RC 90476 HCPCS outpatient 260 195 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 234 90 999999999 202.8 247 percent of total billed charges "ADENOVIRUS VACCINE, TYPE 4, LIVE, FOR ORAL USE" 6369047601_1 CDM 636 RC 90476 HCPCS outpatient 260 195 AETNA MCR ADV AETNA MCR ADV 202.8 78 999999999 202.8 247 percent of total billed charges "ADENOVIRUS VACCINE, TYPE 4, LIVE, FOR ORAL USE" 6369047601_1 CDM 636 RC 90476 HCPCS outpatient 260 195 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 227.68 87.57 999999999 202.8 247 percent of total billed charges "ADENOVIRUS VACCINE, TYPE 4, LIVE, FOR ORAL USE" 6369047601_1 CDM 636 RC 90476 HCPCS outpatient 260 195 COORDINATED CARE MCAID COORDINATED CARE MCAID 221.18 85.07 999999999 202.8 247 percent of total billed charges "ADENOVIRUS VACCINE, TYPE 4, LIVE, FOR ORAL USE" 6369047601_1 CDM 636 RC 90476 HCPCS outpatient 260 195 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 221.18 85.07 999999999 202.8 247 percent of total billed charges "ADENOVIRUS VACCINE, TYPE 4, LIVE, FOR ORAL USE" 6369047601_1 CDM 636 RC 90476 HCPCS outpatient 260 195 MOLINA MCAID MOLINA MCAID 216.84 83.4 999999999 202.8 247 percent of total billed charges "ADENOVIRUS VACCINE, TYPE 4, LIVE, FOR ORAL USE" 6369047601_1 CDM 636 RC 90476 HCPCS outpatient 260 195 MOLINA MCR ADV MOLINA MCR ADV 231.4 89 999999999 202.8 247 percent of total billed charges "ADENOVIRUS VACCINE, TYPE 4, LIVE, FOR ORAL USE" 6369047601_1 CDM 636 RC 90476 HCPCS outpatient 260 195 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 231.4 89 999999999 202.8 247 percent of total billed charges "ADENOVIRUS VACCINE, TYPE 4, LIVE, FOR ORAL USE" 6369047601_1 CDM 636 RC 90476 HCPCS outpatient 260 195 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 231.4 89 999999999 202.8 247 percent of total billed charges "ADENOVIRUS VACCINE, TYPE 4, LIVE, FOR ORAL USE" 6369047601_1 CDM 636 RC 90476 HCPCS outpatient 260 195 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 234 90 999999999 202.8 247 percent of total billed charges "ADENOVIRUS VACCINE, TYPE 4, LIVE, FOR ORAL USE" 6369047601_1 CDM 636 RC 90476 HCPCS outpatient 260 195 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 247 95 999999999 202.8 247 percent of total billed charges "ADENOVIRUS VACCINE, TYPE 4, LIVE, FOR ORAL USE" 6369047601_1 CDM 636 RC 90476 HCPCS outpatient 260 195 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 247 95 999999999 202.8 247 percent of total billed charges "ADENOVIRUS VACCINE, TYPE 4, LIVE, FOR ORAL USE" 6369047601_1 CDM 636 RC 90476 HCPCS outpatient 260 195 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 231.4 89 999999999 202.8 247 percent of total billed charges "ADENOVIRUS VACCINE, TYPE 4, LIVE, FOR ORAL USE" 6369047601_1 CDM 636 RC 90476 HCPCS outpatient 260 195 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 228.8 88 999999999 202.8 247 percent of total billed charges "ADENOVIRUS VACCINE, TYPE 4, LIVE, FOR ORAL USE" 6369047601_1 CDM 636 RC 90476 HCPCS outpatient 260 195 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 231.4 89 999999999 202.8 247 percent of total billed charges "HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUSCULAR USE" 6369063201_1 CDM 636 RC 90632 HCPCS outpatient 336 252 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 302.4 90 999999999 262.08 319.2 percent of total billed charges "HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUSCULAR USE" 6369063201_1 CDM 636 RC 90632 HCPCS outpatient 336 252 AETNA MCR ADV AETNA MCR ADV 262.08 78 999999999 262.08 319.2 percent of total billed charges "HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUSCULAR USE" 6369063201_1 CDM 636 RC 90632 HCPCS outpatient 336 252 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 294.24 87.57 999999999 262.08 319.2 percent of total billed charges "HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUSCULAR USE" 6369063201_1 CDM 636 RC 90632 HCPCS outpatient 336 252 COORDINATED CARE MCAID COORDINATED CARE MCAID 285.84 85.07 999999999 262.08 319.2 percent of total billed charges "HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUSCULAR USE" 6369063201_1 CDM 636 RC 90632 HCPCS outpatient 336 252 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 285.84 85.07 999999999 262.08 319.2 percent of total billed charges "HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUSCULAR USE" 6369063201_1 CDM 636 RC 90632 HCPCS outpatient 336 252 MOLINA MCAID MOLINA MCAID 280.22 83.4 999999999 262.08 319.2 percent of total billed charges "HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUSCULAR USE" 6369063201_1 CDM 636 RC 90632 HCPCS outpatient 336 252 MOLINA MCR ADV MOLINA MCR ADV 299.04 89 999999999 262.08 319.2 percent of total billed charges "HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUSCULAR USE" 6369063201_1 CDM 636 RC 90632 HCPCS outpatient 336 252 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 299.04 89 999999999 262.08 319.2 percent of total billed charges "HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUSCULAR USE" 6369063201_1 CDM 636 RC 90632 HCPCS outpatient 336 252 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 299.04 89 999999999 262.08 319.2 percent of total billed charges "HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUSCULAR USE" 6369063201_1 CDM 636 RC 90632 HCPCS outpatient 336 252 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 302.4 90 999999999 262.08 319.2 percent of total billed charges "HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUSCULAR USE" 6369063201_1 CDM 636 RC 90632 HCPCS outpatient 336 252 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 319.2 95 999999999 262.08 319.2 percent of total billed charges "HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUSCULAR USE" 6369063201_1 CDM 636 RC 90632 HCPCS outpatient 336 252 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 319.2 95 999999999 262.08 319.2 percent of total billed charges "HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUSCULAR USE" 6369063201_1 CDM 636 RC 90632 HCPCS outpatient 336 252 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 299.04 89 999999999 262.08 319.2 percent of total billed charges "HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUSCULAR USE" 6369063201_1 CDM 636 RC 90632 HCPCS outpatient 336 252 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 295.68 88 999999999 262.08 319.2 percent of total billed charges "HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUSCULAR USE" 6369063201_1 CDM 636 RC 90632 HCPCS outpatient 336 252 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 299.04 89 999999999 262.08 319.2 percent of total billed charges "TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), PRESERVATIVE FREE, WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 6369071401_1 CDM 636 RC 90714 HCPCS outpatient 336 252 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 302.4 90 999999999 262.08 319.2 percent of total billed charges "TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), PRESERVATIVE FREE, WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 6369071401_1 CDM 636 RC 90714 HCPCS outpatient 336 252 AETNA MCR ADV AETNA MCR ADV 262.08 78 999999999 262.08 319.2 percent of total billed charges "TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), PRESERVATIVE FREE, WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 6369071401_1 CDM 636 RC 90714 HCPCS outpatient 336 252 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 294.24 87.57 999999999 262.08 319.2 percent of total billed charges "TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), PRESERVATIVE FREE, WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 6369071401_1 CDM 636 RC 90714 HCPCS outpatient 336 252 COORDINATED CARE MCAID COORDINATED CARE MCAID 285.84 85.07 999999999 262.08 319.2 percent of total billed charges "TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), PRESERVATIVE FREE, WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 6369071401_1 CDM 636 RC 90714 HCPCS outpatient 336 252 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 285.84 85.07 999999999 262.08 319.2 percent of total billed charges "TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), PRESERVATIVE FREE, WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 6369071401_1 CDM 636 RC 90714 HCPCS outpatient 336 252 MOLINA MCAID MOLINA MCAID 280.22 83.4 999999999 262.08 319.2 percent of total billed charges "TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), PRESERVATIVE FREE, WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 6369071401_1 CDM 636 RC 90714 HCPCS outpatient 336 252 MOLINA MCR ADV MOLINA MCR ADV 299.04 89 999999999 262.08 319.2 percent of total billed charges "TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), PRESERVATIVE FREE, WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 6369071401_1 CDM 636 RC 90714 HCPCS outpatient 336 252 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 299.04 89 999999999 262.08 319.2 percent of total billed charges "TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), PRESERVATIVE FREE, WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 6369071401_1 CDM 636 RC 90714 HCPCS outpatient 336 252 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 299.04 89 999999999 262.08 319.2 percent of total billed charges "TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), PRESERVATIVE FREE, WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 6369071401_1 CDM 636 RC 90714 HCPCS outpatient 336 252 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 302.4 90 999999999 262.08 319.2 percent of total billed charges "TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), PRESERVATIVE FREE, WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 6369071401_1 CDM 636 RC 90714 HCPCS outpatient 336 252 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 319.2 95 999999999 262.08 319.2 percent of total billed charges "TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), PRESERVATIVE FREE, WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 6369071401_1 CDM 636 RC 90714 HCPCS outpatient 336 252 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 319.2 95 999999999 262.08 319.2 percent of total billed charges "TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), PRESERVATIVE FREE, WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 6369071401_1 CDM 636 RC 90714 HCPCS outpatient 336 252 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 299.04 89 999999999 262.08 319.2 percent of total billed charges "TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), PRESERVATIVE FREE, WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 6369071401_1 CDM 636 RC 90714 HCPCS outpatient 336 252 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 295.68 88 999999999 262.08 319.2 percent of total billed charges "TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), PRESERVATIVE FREE, WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 6369071401_1 CDM 636 RC 90714 HCPCS outpatient 336 252 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 299.04 89 999999999 262.08 319.2 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 64400_1 CDM 360 RC 64400 HCPCS outpatient 150.15 112.61 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 135.14 999999999 117.12 142.64 case rate "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 64400_1 CDM 360 RC 64400 HCPCS outpatient 150.15 112.61 AETNA MCR ADV AETNA MCR ADV 117.12 78 999999999 117.12 142.64 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 64400_1 CDM 360 RC 64400 HCPCS outpatient 150.15 112.61 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 131.49 87.57 999999999 117.12 142.64 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 64400_1 CDM 360 RC 64400 HCPCS outpatient 150.15 112.61 COORDINATED CARE MCAID COORDINATED CARE MCAID 127.73 85.07 999999999 117.12 142.64 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 64400_1 CDM 360 RC 64400 HCPCS outpatient 150.15 112.61 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 127.73 85.07 999999999 117.12 142.64 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 64400_1 CDM 360 RC 64400 HCPCS outpatient 150.15 112.61 MOLINA MCAID MOLINA MCAID 125.23 83.4 999999999 117.12 142.64 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 64400_1 CDM 360 RC 64400 HCPCS outpatient 150.15 112.61 MOLINA MCR ADV MOLINA MCR ADV 133.63 89 999999999 117.12 142.64 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 64400_1 CDM 360 RC 64400 HCPCS outpatient 150.15 112.61 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 133.63 89 999999999 117.12 142.64 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 64400_1 CDM 360 RC 64400 HCPCS outpatient 150.15 112.61 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 133.63 89 999999999 117.12 142.64 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 64400_1 CDM 360 RC 64400 HCPCS outpatient 150.15 112.61 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 135.14 90 999999999 117.12 142.64 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 64400_1 CDM 360 RC 64400 HCPCS outpatient 150.15 112.61 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 142.64 95 999999999 117.12 142.64 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 64400_1 CDM 360 RC 64400 HCPCS outpatient 150.15 112.61 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 142.64 95 999999999 117.12 142.64 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 64400_1 CDM 360 RC 64400 HCPCS outpatient 150.15 112.61 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 133.63 89 999999999 117.12 142.64 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 64400_1 CDM 360 RC 64400 HCPCS outpatient 150.15 112.61 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 132.13 88 999999999 117.12 142.64 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 64400_1 CDM 360 RC 64400 HCPCS outpatient 150.15 112.61 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 133.63 89 999999999 117.12 142.64 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GREATER OCCIPITAL NERVE" 64405_1 CDM 490 RC 64405 HCPCS outpatient 567 425.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 510.3 999999999 442.26 538.65 case rate "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GREATER OCCIPITAL NERVE" 64405_1 CDM 490 RC 64405 HCPCS outpatient 567 425.25 AETNA MCR ADV AETNA MCR ADV 442.26 78 999999999 442.26 538.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GREATER OCCIPITAL NERVE" 64405_1 CDM 490 RC 64405 HCPCS outpatient 567 425.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 496.52 87.57 999999999 442.26 538.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GREATER OCCIPITAL NERVE" 64405_1 CDM 490 RC 64405 HCPCS outpatient 567 425.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 482.35 85.07 999999999 442.26 538.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GREATER OCCIPITAL NERVE" 64405_1 CDM 490 RC 64405 HCPCS outpatient 567 425.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 482.35 85.07 999999999 442.26 538.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GREATER OCCIPITAL NERVE" 64405_1 CDM 490 RC 64405 HCPCS outpatient 567 425.25 MOLINA MCAID MOLINA MCAID 472.88 83.4 999999999 442.26 538.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GREATER OCCIPITAL NERVE" 64405_1 CDM 490 RC 64405 HCPCS outpatient 567 425.25 MOLINA MCR ADV MOLINA MCR ADV 504.63 89 999999999 442.26 538.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GREATER OCCIPITAL NERVE" 64405_1 CDM 490 RC 64405 HCPCS outpatient 567 425.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 504.63 89 999999999 442.26 538.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GREATER OCCIPITAL NERVE" 64405_1 CDM 490 RC 64405 HCPCS outpatient 567 425.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 504.63 89 999999999 442.26 538.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GREATER OCCIPITAL NERVE" 64405_1 CDM 490 RC 64405 HCPCS outpatient 567 425.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 510.3 90 999999999 442.26 538.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GREATER OCCIPITAL NERVE" 64405_1 CDM 490 RC 64405 HCPCS outpatient 567 425.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 538.65 95 999999999 442.26 538.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GREATER OCCIPITAL NERVE" 64405_1 CDM 490 RC 64405 HCPCS outpatient 567 425.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 538.65 95 999999999 442.26 538.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GREATER OCCIPITAL NERVE" 64405_1 CDM 490 RC 64405 HCPCS outpatient 567 425.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 504.63 89 999999999 442.26 538.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GREATER OCCIPITAL NERVE" 64405_1 CDM 490 RC 64405 HCPCS outpatient 567 425.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 498.96 88 999999999 442.26 538.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GREATER OCCIPITAL NERVE" 64405_1 CDM 490 RC 64405 HCPCS outpatient 567 425.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 504.63 89 999999999 442.26 538.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64417_1 CDM 960 RC 64417 HCPCS outpatient 567 425.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 186.82 999999999 86.83 567 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64417_1 CDM 960 RC 64417 HCPCS outpatient 567 425.25 AETNA MCR ADV AETNA MCR ADV 567 999999999 86.83 567 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64417_1 CDM 960 RC 64417 HCPCS outpatient 567 425.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 99.09 999999999 86.83 567 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64417_1 CDM 960 RC 64417 HCPCS outpatient 567 425.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 94.37 999999999 86.83 567 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64417_1 CDM 960 RC 64417 HCPCS outpatient 567 425.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 567 999999999 86.83 567 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64417_1 CDM 960 RC 64417 HCPCS outpatient 567 425.25 MOLINA MCAID MOLINA MCAID 99.09 999999999 86.83 567 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64417_1 CDM 960 RC 64417 HCPCS outpatient 567 425.25 MOLINA MCR ADV MOLINA MCR ADV 567 999999999 86.83 567 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64417_1 CDM 960 RC 64417 HCPCS outpatient 567 425.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 567 999999999 86.83 567 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64417_1 CDM 960 RC 64417 HCPCS outpatient 567 425.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 567 999999999 86.83 567 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64417_1 CDM 960 RC 64417 HCPCS outpatient 567 425.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 176.64 999999999 86.83 567 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64417_1 CDM 960 RC 64417 HCPCS outpatient 567 425.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 101 999999999 86.83 567 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64417_1 CDM 960 RC 64417 HCPCS outpatient 567 425.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 101 999999999 86.83 567 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64417_1 CDM 960 RC 64417 HCPCS outpatient 567 425.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 567 999999999 86.83 567 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64417_1 CDM 960 RC 64417 HCPCS outpatient 567 425.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 86.83 999999999 86.83 567 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64417_1 CDM 960 RC 64417 HCPCS outpatient 567 425.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 567 999999999 86.83 567 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE" 64418_1 CDM 360 RC 64418 HCPCS outpatient 567 425.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 510.3 999999999 442.26 538.65 case rate "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE" 64418_1 CDM 360 RC 64418 HCPCS outpatient 567 425.25 AETNA MCR ADV AETNA MCR ADV 442.26 78 999999999 442.26 538.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE" 64418_1 CDM 360 RC 64418 HCPCS outpatient 567 425.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 496.52 87.57 999999999 442.26 538.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE" 64418_1 CDM 360 RC 64418 HCPCS outpatient 567 425.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 482.35 85.07 999999999 442.26 538.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE" 64418_1 CDM 360 RC 64418 HCPCS outpatient 567 425.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 482.35 85.07 999999999 442.26 538.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE" 64418_1 CDM 360 RC 64418 HCPCS outpatient 567 425.25 MOLINA MCAID MOLINA MCAID 472.88 83.4 999999999 442.26 538.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE" 64418_1 CDM 360 RC 64418 HCPCS outpatient 567 425.25 MOLINA MCR ADV MOLINA MCR ADV 504.63 89 999999999 442.26 538.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE" 64418_1 CDM 360 RC 64418 HCPCS outpatient 567 425.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 504.63 89 999999999 442.26 538.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE" 64418_1 CDM 360 RC 64418 HCPCS outpatient 567 425.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 504.63 89 999999999 442.26 538.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE" 64418_1 CDM 360 RC 64418 HCPCS outpatient 567 425.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 510.3 90 999999999 442.26 538.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE" 64418_1 CDM 360 RC 64418 HCPCS outpatient 567 425.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 538.65 95 999999999 442.26 538.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE" 64418_1 CDM 360 RC 64418 HCPCS outpatient 567 425.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 538.65 95 999999999 442.26 538.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE" 64418_1 CDM 360 RC 64418 HCPCS outpatient 567 425.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 504.63 89 999999999 442.26 538.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE" 64418_1 CDM 360 RC 64418 HCPCS outpatient 567 425.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 498.96 88 999999999 442.26 538.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE" 64418_1 CDM 360 RC 64418 HCPCS outpatient 567 425.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 504.63 89 999999999 442.26 538.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, SINGLE LEVEL" 64420_1 CDM 490 RC 64420 HCPCS outpatient 177.48 133.11 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 159.73 999999999 138.43 168.61 case rate "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, SINGLE LEVEL" 64420_1 CDM 490 RC 64420 HCPCS outpatient 177.48 133.11 AETNA MCR ADV AETNA MCR ADV 138.43 78 999999999 138.43 168.61 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, SINGLE LEVEL" 64420_1 CDM 490 RC 64420 HCPCS outpatient 177.48 133.11 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 155.42 87.57 999999999 138.43 168.61 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, SINGLE LEVEL" 64420_1 CDM 490 RC 64420 HCPCS outpatient 177.48 133.11 COORDINATED CARE MCAID COORDINATED CARE MCAID 150.98 85.07 999999999 138.43 168.61 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, SINGLE LEVEL" 64420_1 CDM 490 RC 64420 HCPCS outpatient 177.48 133.11 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 150.98 85.07 999999999 138.43 168.61 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, SINGLE LEVEL" 64420_1 CDM 490 RC 64420 HCPCS outpatient 177.48 133.11 MOLINA MCAID MOLINA MCAID 148.02 83.4 999999999 138.43 168.61 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, SINGLE LEVEL" 64420_1 CDM 490 RC 64420 HCPCS outpatient 177.48 133.11 MOLINA MCR ADV MOLINA MCR ADV 157.96 89 999999999 138.43 168.61 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, SINGLE LEVEL" 64420_1 CDM 490 RC 64420 HCPCS outpatient 177.48 133.11 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 157.96 89 999999999 138.43 168.61 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, SINGLE LEVEL" 64420_1 CDM 490 RC 64420 HCPCS outpatient 177.48 133.11 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 157.96 89 999999999 138.43 168.61 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, SINGLE LEVEL" 64420_1 CDM 490 RC 64420 HCPCS outpatient 177.48 133.11 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 159.73 90 999999999 138.43 168.61 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, SINGLE LEVEL" 64420_1 CDM 490 RC 64420 HCPCS outpatient 177.48 133.11 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 168.61 95 999999999 138.43 168.61 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, SINGLE LEVEL" 64420_1 CDM 490 RC 64420 HCPCS outpatient 177.48 133.11 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 168.61 95 999999999 138.43 168.61 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, SINGLE LEVEL" 64420_1 CDM 490 RC 64420 HCPCS outpatient 177.48 133.11 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 157.96 89 999999999 138.43 168.61 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, SINGLE LEVEL" 64420_1 CDM 490 RC 64420 HCPCS outpatient 177.48 133.11 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 156.18 88 999999999 138.43 168.61 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, SINGLE LEVEL" 64420_1 CDM 490 RC 64420 HCPCS outpatient 177.48 133.11 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 157.96 89 999999999 138.43 168.61 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64421_1 CDM 490 RC 64421 HCPCS outpatient 74.73 56.05 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 67.26 999999999 58.29 70.99 case rate "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64421_1 CDM 490 RC 64421 HCPCS outpatient 74.73 56.05 AETNA MCR ADV AETNA MCR ADV 58.29 78 999999999 58.29 70.99 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64421_1 CDM 490 RC 64421 HCPCS outpatient 74.73 56.05 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 65.44 87.57 999999999 58.29 70.99 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64421_1 CDM 490 RC 64421 HCPCS outpatient 74.73 56.05 COORDINATED CARE MCAID COORDINATED CARE MCAID 63.57 85.07 999999999 58.29 70.99 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64421_1 CDM 490 RC 64421 HCPCS outpatient 74.73 56.05 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 63.57 85.07 999999999 58.29 70.99 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64421_1 CDM 490 RC 64421 HCPCS outpatient 74.73 56.05 MOLINA MCAID MOLINA MCAID 62.32 83.4 999999999 58.29 70.99 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64421_1 CDM 490 RC 64421 HCPCS outpatient 74.73 56.05 MOLINA MCR ADV MOLINA MCR ADV 66.51 89 999999999 58.29 70.99 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64421_1 CDM 490 RC 64421 HCPCS outpatient 74.73 56.05 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 66.51 89 999999999 58.29 70.99 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64421_1 CDM 490 RC 64421 HCPCS outpatient 74.73 56.05 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 66.51 89 999999999 58.29 70.99 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64421_1 CDM 490 RC 64421 HCPCS outpatient 74.73 56.05 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 67.26 90 999999999 58.29 70.99 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64421_1 CDM 490 RC 64421 HCPCS outpatient 74.73 56.05 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 70.99 95 999999999 58.29 70.99 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64421_1 CDM 490 RC 64421 HCPCS outpatient 74.73 56.05 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 70.99 95 999999999 58.29 70.99 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64421_1 CDM 490 RC 64421 HCPCS outpatient 74.73 56.05 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 66.51 89 999999999 58.29 70.99 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64421_1 CDM 490 RC 64421 HCPCS outpatient 74.73 56.05 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 65.76 88 999999999 58.29 70.99 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64421_1 CDM 490 RC 64421 HCPCS outpatient 74.73 56.05 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 66.51 89 999999999 58.29 70.99 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64445_1 CDM 360 RC 64445 HCPCS outpatient 770 577.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 693 999999999 600.6 731.5 case rate "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64445_1 CDM 360 RC 64445 HCPCS outpatient 770 577.5 AETNA MCR ADV AETNA MCR ADV 600.6 78 999999999 600.6 731.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64445_1 CDM 360 RC 64445 HCPCS outpatient 770 577.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 674.29 87.57 999999999 600.6 731.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64445_1 CDM 360 RC 64445 HCPCS outpatient 770 577.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 655.04 85.07 999999999 600.6 731.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64445_1 CDM 360 RC 64445 HCPCS outpatient 770 577.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 655.04 85.07 999999999 600.6 731.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64445_1 CDM 360 RC 64445 HCPCS outpatient 770 577.5 MOLINA MCAID MOLINA MCAID 642.18 83.4 999999999 600.6 731.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64445_1 CDM 360 RC 64445 HCPCS outpatient 770 577.5 MOLINA MCR ADV MOLINA MCR ADV 685.3 89 999999999 600.6 731.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64445_1 CDM 360 RC 64445 HCPCS outpatient 770 577.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 685.3 89 999999999 600.6 731.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64445_1 CDM 360 RC 64445 HCPCS outpatient 770 577.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 685.3 89 999999999 600.6 731.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64445_1 CDM 360 RC 64445 HCPCS outpatient 770 577.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 693 90 999999999 600.6 731.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64445_1 CDM 360 RC 64445 HCPCS outpatient 770 577.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 731.5 95 999999999 600.6 731.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64445_1 CDM 360 RC 64445 HCPCS outpatient 770 577.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 731.5 95 999999999 600.6 731.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64445_1 CDM 360 RC 64445 HCPCS outpatient 770 577.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 685.3 89 999999999 600.6 731.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64445_1 CDM 360 RC 64445 HCPCS outpatient 770 577.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 677.6 88 999999999 600.6 731.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64445_1 CDM 360 RC 64445 HCPCS outpatient 770 577.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 685.3 89 999999999 600.6 731.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64445_50_1 CDM 360 RC 64445 HCPCS outpatient 1156 867 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 1040.4 999999999 901.68 1098.2 case rate "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64445_50_1 CDM 360 RC 64445 HCPCS outpatient 1156 867 AETNA MCR ADV AETNA MCR ADV 50 901.68 78 999999999 901.68 1098.2 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64445_50_1 CDM 360 RC 64445 HCPCS outpatient 1156 867 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 1012.31 87.57 999999999 901.68 1098.2 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64445_50_1 CDM 360 RC 64445 HCPCS outpatient 1156 867 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 983.41 85.07 999999999 901.68 1098.2 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64445_50_1 CDM 360 RC 64445 HCPCS outpatient 1156 867 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 983.41 85.07 999999999 901.68 1098.2 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64445_50_1 CDM 360 RC 64445 HCPCS outpatient 1156 867 MOLINA MCAID MOLINA MCAID 50 964.1 83.4 999999999 901.68 1098.2 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64445_50_1 CDM 360 RC 64445 HCPCS outpatient 1156 867 MOLINA MCR ADV MOLINA MCR ADV 50 1028.84 89 999999999 901.68 1098.2 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64445_50_1 CDM 360 RC 64445 HCPCS outpatient 1156 867 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 1028.84 89 999999999 901.68 1098.2 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64445_50_1 CDM 360 RC 64445 HCPCS outpatient 1156 867 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 1028.84 89 999999999 901.68 1098.2 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64445_50_1 CDM 360 RC 64445 HCPCS outpatient 1156 867 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 1040.4 90 999999999 901.68 1098.2 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64445_50_1 CDM 360 RC 64445 HCPCS outpatient 1156 867 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 1098.2 95 999999999 901.68 1098.2 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64445_50_1 CDM 360 RC 64445 HCPCS outpatient 1156 867 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 1098.2 95 999999999 901.68 1098.2 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64445_50_1 CDM 360 RC 64445 HCPCS outpatient 1156 867 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 1028.84 89 999999999 901.68 1098.2 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64445_50_1 CDM 360 RC 64445 HCPCS outpatient 1156 867 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 1017.28 88 999999999 901.68 1098.2 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64445_50_1 CDM 360 RC 64445 HCPCS outpatient 1156 867 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 1028.84 89 999999999 901.68 1098.2 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64447_1 CDM 360 RC 64447 HCPCS outpatient 1247 935.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1122.3 999999999 972.66 1184.65 case rate "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64447_1 CDM 360 RC 64447 HCPCS outpatient 1247 935.25 AETNA MCR ADV AETNA MCR ADV 972.66 78 999999999 972.66 1184.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64447_1 CDM 360 RC 64447 HCPCS outpatient 1247 935.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1092 87.57 999999999 972.66 1184.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64447_1 CDM 360 RC 64447 HCPCS outpatient 1247 935.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 1060.82 85.07 999999999 972.66 1184.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64447_1 CDM 360 RC 64447 HCPCS outpatient 1247 935.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1060.82 85.07 999999999 972.66 1184.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64447_1 CDM 360 RC 64447 HCPCS outpatient 1247 935.25 MOLINA MCAID MOLINA MCAID 1040 83.4 999999999 972.66 1184.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64447_1 CDM 360 RC 64447 HCPCS outpatient 1247 935.25 MOLINA MCR ADV MOLINA MCR ADV 1109.83 89 999999999 972.66 1184.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64447_1 CDM 360 RC 64447 HCPCS outpatient 1247 935.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1109.83 89 999999999 972.66 1184.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64447_1 CDM 360 RC 64447 HCPCS outpatient 1247 935.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1109.83 89 999999999 972.66 1184.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64447_1 CDM 360 RC 64447 HCPCS outpatient 1247 935.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1122.3 90 999999999 972.66 1184.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64447_1 CDM 360 RC 64447 HCPCS outpatient 1247 935.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1184.65 95 999999999 972.66 1184.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64447_1 CDM 360 RC 64447 HCPCS outpatient 1247 935.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1184.65 95 999999999 972.66 1184.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64447_1 CDM 360 RC 64447 HCPCS outpatient 1247 935.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1109.83 89 999999999 972.66 1184.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64447_1 CDM 360 RC 64447 HCPCS outpatient 1247 935.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1097.36 88 999999999 972.66 1184.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64447_1 CDM 360 RC 64447 HCPCS outpatient 1247 935.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1109.83 89 999999999 972.66 1184.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 64450_1 CDM 490 RC 64450 HCPCS outpatient 126.93 95.2 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 114.24 999999999 99.01 120.58 case rate "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 64450_1 CDM 490 RC 64450 HCPCS outpatient 126.93 95.2 AETNA MCR ADV AETNA MCR ADV 99.01 78 999999999 99.01 120.58 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 64450_1 CDM 490 RC 64450 HCPCS outpatient 126.93 95.2 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 111.15 87.57 999999999 99.01 120.58 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 64450_1 CDM 490 RC 64450 HCPCS outpatient 126.93 95.2 COORDINATED CARE MCAID COORDINATED CARE MCAID 107.98 85.07 999999999 99.01 120.58 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 64450_1 CDM 490 RC 64450 HCPCS outpatient 126.93 95.2 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 107.98 85.07 999999999 99.01 120.58 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 64450_1 CDM 490 RC 64450 HCPCS outpatient 126.93 95.2 MOLINA MCAID MOLINA MCAID 105.86 83.4 999999999 99.01 120.58 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 64450_1 CDM 490 RC 64450 HCPCS outpatient 126.93 95.2 MOLINA MCR ADV MOLINA MCR ADV 112.97 89 999999999 99.01 120.58 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 64450_1 CDM 490 RC 64450 HCPCS outpatient 126.93 95.2 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 112.97 89 999999999 99.01 120.58 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 64450_1 CDM 490 RC 64450 HCPCS outpatient 126.93 95.2 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 112.97 89 999999999 99.01 120.58 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 64450_1 CDM 490 RC 64450 HCPCS outpatient 126.93 95.2 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 114.24 90 999999999 99.01 120.58 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 64450_1 CDM 490 RC 64450 HCPCS outpatient 126.93 95.2 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 120.58 95 999999999 99.01 120.58 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 64450_1 CDM 490 RC 64450 HCPCS outpatient 126.93 95.2 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 120.58 95 999999999 99.01 120.58 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 64450_1 CDM 490 RC 64450 HCPCS outpatient 126.93 95.2 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 112.97 89 999999999 99.01 120.58 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 64450_1 CDM 490 RC 64450 HCPCS outpatient 126.93 95.2 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 111.7 88 999999999 99.01 120.58 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 64450_1 CDM 490 RC 64450 HCPCS outpatient 126.93 95.2 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 112.97 89 999999999 99.01 120.58 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 64450_2 CDM 490 RC 64450 HCPCS outpatient 126.93 95.2 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 114.24 999999999 99.01 120.58 case rate "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 64450_2 CDM 490 RC 64450 HCPCS outpatient 126.93 95.2 AETNA MCR ADV AETNA MCR ADV 99.01 78 999999999 99.01 120.58 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 64450_2 CDM 490 RC 64450 HCPCS outpatient 126.93 95.2 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 111.15 87.57 999999999 99.01 120.58 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 64450_2 CDM 490 RC 64450 HCPCS outpatient 126.93 95.2 COORDINATED CARE MCAID COORDINATED CARE MCAID 107.98 85.07 999999999 99.01 120.58 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 64450_2 CDM 490 RC 64450 HCPCS outpatient 126.93 95.2 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 107.98 85.07 999999999 99.01 120.58 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 64450_2 CDM 490 RC 64450 HCPCS outpatient 126.93 95.2 MOLINA MCAID MOLINA MCAID 105.86 83.4 999999999 99.01 120.58 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 64450_2 CDM 490 RC 64450 HCPCS outpatient 126.93 95.2 MOLINA MCR ADV MOLINA MCR ADV 112.97 89 999999999 99.01 120.58 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 64450_2 CDM 490 RC 64450 HCPCS outpatient 126.93 95.2 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 112.97 89 999999999 99.01 120.58 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 64450_2 CDM 490 RC 64450 HCPCS outpatient 126.93 95.2 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 112.97 89 999999999 99.01 120.58 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 64450_2 CDM 490 RC 64450 HCPCS outpatient 126.93 95.2 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 114.24 90 999999999 99.01 120.58 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 64450_2 CDM 490 RC 64450 HCPCS outpatient 126.93 95.2 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 120.58 95 999999999 99.01 120.58 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 64450_2 CDM 490 RC 64450 HCPCS outpatient 126.93 95.2 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 120.58 95 999999999 99.01 120.58 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 64450_2 CDM 490 RC 64450 HCPCS outpatient 126.93 95.2 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 112.97 89 999999999 99.01 120.58 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 64450_2 CDM 490 RC 64450 HCPCS outpatient 126.93 95.2 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 111.7 88 999999999 99.01 120.58 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 64450_2 CDM 490 RC 64450 HCPCS outpatient 126.93 95.2 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 112.97 89 999999999 99.01 120.58 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 64451_1 CDM 960 RC 64451 HCPCS outpatient 1200 900 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 300.47 999999999 111.05 1260 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 64451_1 CDM 960 RC 64451 HCPCS outpatient 1200 900 AETNA MCR ADV AETNA MCR ADV 1200 999999999 111.05 1260 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 64451_1 CDM 960 RC 64451 HCPCS outpatient 1200 900 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1260 999999999 111.05 1260 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 64451_1 CDM 960 RC 64451 HCPCS outpatient 1200 900 COORDINATED CARE MCAID COORDINATED CARE MCAID 1200 999999999 111.05 1260 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 64451_1 CDM 960 RC 64451 HCPCS outpatient 1200 900 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1200 999999999 111.05 1260 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 64451_1 CDM 960 RC 64451 HCPCS outpatient 1200 900 MOLINA MCAID MOLINA MCAID 1260 999999999 111.05 1260 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 64451_1 CDM 960 RC 64451 HCPCS outpatient 1200 900 MOLINA MCR ADV MOLINA MCR ADV 1200 999999999 111.05 1260 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 64451_1 CDM 960 RC 64451 HCPCS outpatient 1200 900 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1200 999999999 111.05 1260 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 64451_1 CDM 960 RC 64451 HCPCS outpatient 1200 900 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1200 999999999 111.05 1260 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 64451_1 CDM 960 RC 64451 HCPCS outpatient 1200 900 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 287.52 999999999 111.05 1260 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 64451_1 CDM 960 RC 64451 HCPCS outpatient 1200 900 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 999999999 111.05 1260 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 64451_1 CDM 960 RC 64451 HCPCS outpatient 1200 900 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 999999999 111.05 1260 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 64451_1 CDM 960 RC 64451 HCPCS outpatient 1200 900 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1200 999999999 111.05 1260 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 64451_1 CDM 960 RC 64451 HCPCS outpatient 1200 900 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 111.05 999999999 111.05 1260 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 64451_1 CDM 960 RC 64451 HCPCS outpatient 1200 900 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1200 999999999 111.05 1260 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 64451_50_1 CDM 960 RC 64451 HCPCS outpatient 1800 1350 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 300.47 999999999 111.05 1890 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 64451_50_1 CDM 960 RC 64451 HCPCS outpatient 1800 1350 AETNA MCR ADV AETNA MCR ADV 50 1800 999999999 111.05 1890 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 64451_50_1 CDM 960 RC 64451 HCPCS outpatient 1800 1350 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 1890 999999999 111.05 1890 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 64451_50_1 CDM 960 RC 64451 HCPCS outpatient 1800 1350 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 1800 999999999 111.05 1890 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 64451_50_1 CDM 960 RC 64451 HCPCS outpatient 1800 1350 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 1800 999999999 111.05 1890 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 64451_50_1 CDM 960 RC 64451 HCPCS outpatient 1800 1350 MOLINA MCAID MOLINA MCAID 50 1890 999999999 111.05 1890 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 64451_50_1 CDM 960 RC 64451 HCPCS outpatient 1800 1350 MOLINA MCR ADV MOLINA MCR ADV 50 1800 999999999 111.05 1890 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 64451_50_1 CDM 960 RC 64451 HCPCS outpatient 1800 1350 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 1800 999999999 111.05 1890 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 64451_50_1 CDM 960 RC 64451 HCPCS outpatient 1800 1350 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 1800 999999999 111.05 1890 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 64451_50_1 CDM 960 RC 64451 HCPCS outpatient 1800 1350 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 287.52 999999999 111.05 1890 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 64451_50_1 CDM 960 RC 64451 HCPCS outpatient 1800 1350 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 999999999 111.05 1890 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 64451_50_1 CDM 960 RC 64451 HCPCS outpatient 1800 1350 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 999999999 111.05 1890 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 64451_50_1 CDM 960 RC 64451 HCPCS outpatient 1800 1350 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 1800 999999999 111.05 1890 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 64451_50_1 CDM 960 RC 64451 HCPCS outpatient 1800 1350 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 111.05 999999999 111.05 1890 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 64451_50_1 CDM 960 RC 64451 HCPCS outpatient 1800 1350 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 1800 999999999 111.05 1890 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GENICULAR NERVE BRANCHES, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64454_1 CDM 960 RC 64454 HCPCS outpatient 1620 1215 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 299.52 999999999 111.97 1701 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GENICULAR NERVE BRANCHES, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64454_1 CDM 960 RC 64454 HCPCS outpatient 1620 1215 AETNA MCR ADV AETNA MCR ADV 1620 999999999 111.97 1701 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GENICULAR NERVE BRANCHES, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64454_1 CDM 960 RC 64454 HCPCS outpatient 1620 1215 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1701 999999999 111.97 1701 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GENICULAR NERVE BRANCHES, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64454_1 CDM 960 RC 64454 HCPCS outpatient 1620 1215 COORDINATED CARE MCAID COORDINATED CARE MCAID 1620 999999999 111.97 1701 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GENICULAR NERVE BRANCHES, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64454_1 CDM 960 RC 64454 HCPCS outpatient 1620 1215 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1620 999999999 111.97 1701 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GENICULAR NERVE BRANCHES, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64454_1 CDM 960 RC 64454 HCPCS outpatient 1620 1215 MOLINA MCAID MOLINA MCAID 1701 999999999 111.97 1701 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GENICULAR NERVE BRANCHES, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64454_1 CDM 960 RC 64454 HCPCS outpatient 1620 1215 MOLINA MCR ADV MOLINA MCR ADV 1620 999999999 111.97 1701 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GENICULAR NERVE BRANCHES, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64454_1 CDM 960 RC 64454 HCPCS outpatient 1620 1215 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1620 999999999 111.97 1701 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GENICULAR NERVE BRANCHES, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64454_1 CDM 960 RC 64454 HCPCS outpatient 1620 1215 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1620 999999999 111.97 1701 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GENICULAR NERVE BRANCHES, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64454_1 CDM 960 RC 64454 HCPCS outpatient 1620 1215 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 290.41 999999999 111.97 1701 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GENICULAR NERVE BRANCHES, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64454_1 CDM 960 RC 64454 HCPCS outpatient 1620 1215 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 999999999 111.97 1701 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GENICULAR NERVE BRANCHES, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64454_1 CDM 960 RC 64454 HCPCS outpatient 1620 1215 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 999999999 111.97 1701 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GENICULAR NERVE BRANCHES, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64454_1 CDM 960 RC 64454 HCPCS outpatient 1620 1215 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1620 999999999 111.97 1701 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GENICULAR NERVE BRANCHES, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64454_1 CDM 960 RC 64454 HCPCS outpatient 1620 1215 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 111.97 999999999 111.97 1701 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GENICULAR NERVE BRANCHES, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64454_1 CDM 960 RC 64454 HCPCS outpatient 1620 1215 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1620 999999999 111.97 1701 fee schedule "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_1 CDM 490 RC 64483 HCPCS outpatient 1499 1124.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1349.1 999999999 1169.22 1424.05 case rate "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_1 CDM 490 RC 64483 HCPCS outpatient 1499 1124.25 AETNA MCR ADV AETNA MCR ADV 1169.22 78 999999999 1169.22 1424.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_1 CDM 490 RC 64483 HCPCS outpatient 1499 1124.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1312.67 87.57 999999999 1169.22 1424.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_1 CDM 490 RC 64483 HCPCS outpatient 1499 1124.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 1275.2 85.07 999999999 1169.22 1424.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_1 CDM 490 RC 64483 HCPCS outpatient 1499 1124.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1275.2 85.07 999999999 1169.22 1424.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_1 CDM 490 RC 64483 HCPCS outpatient 1499 1124.25 MOLINA MCAID MOLINA MCAID 1250.17 83.4 999999999 1169.22 1424.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_1 CDM 490 RC 64483 HCPCS outpatient 1499 1124.25 MOLINA MCR ADV MOLINA MCR ADV 1334.11 89 999999999 1169.22 1424.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_1 CDM 490 RC 64483 HCPCS outpatient 1499 1124.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1334.11 89 999999999 1169.22 1424.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_1 CDM 490 RC 64483 HCPCS outpatient 1499 1124.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1334.11 89 999999999 1169.22 1424.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_1 CDM 490 RC 64483 HCPCS outpatient 1499 1124.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1349.1 90 999999999 1169.22 1424.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_1 CDM 490 RC 64483 HCPCS outpatient 1499 1124.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1424.05 95 999999999 1169.22 1424.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_1 CDM 490 RC 64483 HCPCS outpatient 1499 1124.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1424.05 95 999999999 1169.22 1424.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_1 CDM 490 RC 64483 HCPCS outpatient 1499 1124.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1334.11 89 999999999 1169.22 1424.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_1 CDM 490 RC 64483 HCPCS outpatient 1499 1124.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1319.12 88 999999999 1169.22 1424.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_1 CDM 490 RC 64483 HCPCS outpatient 1499 1124.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1334.11 89 999999999 1169.22 1424.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_50 CDM 490 RC 64483 HCPCS inpatient 2249 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 999999999 "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_50 CDM 490 RC 64483 HCPCS inpatient 2249 AETNA MCR ADV AETNA MCR ADV 50 999999999 "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_50 CDM 490 RC 64483 HCPCS inpatient 2249 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 999999999 "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_50 CDM 490 RC 64483 HCPCS inpatient 2249 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 999999999 "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_50 CDM 490 RC 64483 HCPCS inpatient 2249 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 999999999 "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_50 CDM 490 RC 64483 HCPCS inpatient 2249 MOLINA MCAID MOLINA MCAID 50 999999999 "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_50 CDM 490 RC 64483 HCPCS inpatient 2249 MOLINA MCR ADV MOLINA MCR ADV 50 999999999 "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_50 CDM 490 RC 64483 HCPCS inpatient 2249 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 999999999 "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_50 CDM 490 RC 64483 HCPCS inpatient 2249 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 999999999 "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_50 CDM 490 RC 64483 HCPCS inpatient 2249 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 999999999 "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_50 CDM 490 RC 64483 HCPCS inpatient 2249 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 999999999 "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_50 CDM 490 RC 64483 HCPCS inpatient 2249 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 999999999 "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_50 CDM 490 RC 64483 HCPCS inpatient 2249 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 999999999 "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_50 CDM 490 RC 64483 HCPCS inpatient 2249 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 999999999 "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_50 CDM 490 RC 64483 HCPCS inpatient 2249 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 999999999 "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_50_1 CDM 490 RC 64483 HCPCS outpatient 2249 1686.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 2024.1 999999999 1754.22 2136.55 case rate "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_50_1 CDM 490 RC 64483 HCPCS outpatient 2249 1686.75 AETNA MCR ADV AETNA MCR ADV 50 1754.22 78 999999999 1754.22 2136.55 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_50_1 CDM 490 RC 64483 HCPCS outpatient 2249 1686.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 1969.45 87.57 999999999 1754.22 2136.55 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_50_1 CDM 490 RC 64483 HCPCS outpatient 2249 1686.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 1913.22 85.07 999999999 1754.22 2136.55 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_50_1 CDM 490 RC 64483 HCPCS outpatient 2249 1686.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 1913.22 85.07 999999999 1754.22 2136.55 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_50_1 CDM 490 RC 64483 HCPCS outpatient 2249 1686.75 MOLINA MCAID MOLINA MCAID 50 1875.67 83.4 999999999 1754.22 2136.55 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_50_1 CDM 490 RC 64483 HCPCS outpatient 2249 1686.75 MOLINA MCR ADV MOLINA MCR ADV 50 2001.61 89 999999999 1754.22 2136.55 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_50_1 CDM 490 RC 64483 HCPCS outpatient 2249 1686.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 2001.61 89 999999999 1754.22 2136.55 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_50_1 CDM 490 RC 64483 HCPCS outpatient 2249 1686.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 2001.61 89 999999999 1754.22 2136.55 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_50_1 CDM 490 RC 64483 HCPCS outpatient 2249 1686.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 2024.1 90 999999999 1754.22 2136.55 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_50_1 CDM 490 RC 64483 HCPCS outpatient 2249 1686.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 2136.55 95 999999999 1754.22 2136.55 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_50_1 CDM 490 RC 64483 HCPCS outpatient 2249 1686.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 2136.55 95 999999999 1754.22 2136.55 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_50_1 CDM 490 RC 64483 HCPCS outpatient 2249 1686.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 2001.61 89 999999999 1754.22 2136.55 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_50_1 CDM 490 RC 64483 HCPCS outpatient 2249 1686.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 1979.12 88 999999999 1754.22 2136.55 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 64483_50_1 CDM 490 RC 64483 HCPCS outpatient 2249 1686.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 2001.61 89 999999999 1754.22 2136.55 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64484_1 CDM 490 RC 64484 HCPCS outpatient 750 562.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 675 999999999 585 712.5 case rate "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64484_1 CDM 490 RC 64484 HCPCS outpatient 750 562.5 AETNA MCR ADV AETNA MCR ADV 585 78 999999999 585 712.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64484_1 CDM 490 RC 64484 HCPCS outpatient 750 562.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 656.78 87.57 999999999 585 712.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64484_1 CDM 490 RC 64484 HCPCS outpatient 750 562.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 638.03 85.07 999999999 585 712.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64484_1 CDM 490 RC 64484 HCPCS outpatient 750 562.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 638.03 85.07 999999999 585 712.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64484_1 CDM 490 RC 64484 HCPCS outpatient 750 562.5 MOLINA MCAID MOLINA MCAID 625.5 83.4 999999999 585 712.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64484_1 CDM 490 RC 64484 HCPCS outpatient 750 562.5 MOLINA MCR ADV MOLINA MCR ADV 667.5 89 999999999 585 712.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64484_1 CDM 490 RC 64484 HCPCS outpatient 750 562.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 667.5 89 999999999 585 712.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64484_1 CDM 490 RC 64484 HCPCS outpatient 750 562.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 667.5 89 999999999 585 712.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64484_1 CDM 490 RC 64484 HCPCS outpatient 750 562.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 675 90 999999999 585 712.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64484_1 CDM 490 RC 64484 HCPCS outpatient 750 562.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 712.5 95 999999999 585 712.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64484_1 CDM 490 RC 64484 HCPCS outpatient 750 562.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 712.5 95 999999999 585 712.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64484_1 CDM 490 RC 64484 HCPCS outpatient 750 562.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 667.5 89 999999999 585 712.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64484_1 CDM 490 RC 64484 HCPCS outpatient 750 562.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 660 88 999999999 585 712.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64484_1 CDM 490 RC 64484 HCPCS outpatient 750 562.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 667.5 89 999999999 585 712.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64484_50_1 CDM 490 RC 64484 HCPCS outpatient 1124 843 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 1011.6 999999999 876.72 1067.8 case rate "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64484_50_1 CDM 490 RC 64484 HCPCS outpatient 1124 843 AETNA MCR ADV AETNA MCR ADV 50 876.72 78 999999999 876.72 1067.8 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64484_50_1 CDM 490 RC 64484 HCPCS outpatient 1124 843 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 984.29 87.57 999999999 876.72 1067.8 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64484_50_1 CDM 490 RC 64484 HCPCS outpatient 1124 843 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 956.19 85.07 999999999 876.72 1067.8 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64484_50_1 CDM 490 RC 64484 HCPCS outpatient 1124 843 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 956.19 85.07 999999999 876.72 1067.8 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64484_50_1 CDM 490 RC 64484 HCPCS outpatient 1124 843 MOLINA MCAID MOLINA MCAID 50 937.42 83.4 999999999 876.72 1067.8 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64484_50_1 CDM 490 RC 64484 HCPCS outpatient 1124 843 MOLINA MCR ADV MOLINA MCR ADV 50 1000.36 89 999999999 876.72 1067.8 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64484_50_1 CDM 490 RC 64484 HCPCS outpatient 1124 843 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 1000.36 89 999999999 876.72 1067.8 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64484_50_1 CDM 490 RC 64484 HCPCS outpatient 1124 843 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 1000.36 89 999999999 876.72 1067.8 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64484_50_1 CDM 490 RC 64484 HCPCS outpatient 1124 843 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 1011.6 90 999999999 876.72 1067.8 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64484_50_1 CDM 490 RC 64484 HCPCS outpatient 1124 843 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 1067.8 95 999999999 876.72 1067.8 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64484_50_1 CDM 490 RC 64484 HCPCS outpatient 1124 843 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 1067.8 95 999999999 876.72 1067.8 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64484_50_1 CDM 490 RC 64484 HCPCS outpatient 1124 843 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 1000.36 89 999999999 876.72 1067.8 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64484_50_1 CDM 490 RC 64484 HCPCS outpatient 1124 843 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 989.12 88 999999999 876.72 1067.8 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64484_50_1 CDM 490 RC 64484 HCPCS outpatient 1124 843 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 1000.36 89 999999999 876.72 1067.8 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SINGLE LEVEL" 64490_1 CDM 320 RC 64490 HCPCS outpatient 2401 1800.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 2160.9 999999999 1872.78 2280.95 case rate "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SINGLE LEVEL" 64490_1 CDM 320 RC 64490 HCPCS outpatient 2401 1800.75 AETNA MCR ADV AETNA MCR ADV 1872.78 78 999999999 1872.78 2280.95 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SINGLE LEVEL" 64490_1 CDM 320 RC 64490 HCPCS outpatient 2401 1800.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 2102.56 87.57 999999999 1872.78 2280.95 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SINGLE LEVEL" 64490_1 CDM 320 RC 64490 HCPCS outpatient 2401 1800.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 2042.53 85.07 999999999 1872.78 2280.95 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SINGLE LEVEL" 64490_1 CDM 320 RC 64490 HCPCS outpatient 2401 1800.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 2042.53 85.07 999999999 1872.78 2280.95 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SINGLE LEVEL" 64490_1 CDM 320 RC 64490 HCPCS outpatient 2401 1800.75 MOLINA MCAID MOLINA MCAID 2002.43 83.4 999999999 1872.78 2280.95 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SINGLE LEVEL" 64490_1 CDM 320 RC 64490 HCPCS outpatient 2401 1800.75 MOLINA MCR ADV MOLINA MCR ADV 2136.89 89 999999999 1872.78 2280.95 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SINGLE LEVEL" 64490_1 CDM 320 RC 64490 HCPCS outpatient 2401 1800.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 2136.89 89 999999999 1872.78 2280.95 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SINGLE LEVEL" 64490_1 CDM 320 RC 64490 HCPCS outpatient 2401 1800.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 2136.89 89 999999999 1872.78 2280.95 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SINGLE LEVEL" 64490_1 CDM 320 RC 64490 HCPCS outpatient 2401 1800.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 2160.9 90 999999999 1872.78 2280.95 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SINGLE LEVEL" 64490_1 CDM 320 RC 64490 HCPCS outpatient 2401 1800.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 2280.95 95 999999999 1872.78 2280.95 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SINGLE LEVEL" 64490_1 CDM 320 RC 64490 HCPCS outpatient 2401 1800.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 2280.95 95 999999999 1872.78 2280.95 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SINGLE LEVEL" 64490_1 CDM 320 RC 64490 HCPCS outpatient 2401 1800.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 2136.89 89 999999999 1872.78 2280.95 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SINGLE LEVEL" 64490_1 CDM 320 RC 64490 HCPCS outpatient 2401 1800.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 2112.88 88 999999999 1872.78 2280.95 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SINGLE LEVEL" 64490_1 CDM 320 RC 64490 HCPCS outpatient 2401 1800.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 2136.89 89 999999999 1872.78 2280.95 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64491_1 CDM 320 RC 64491 HCPCS outpatient 1018 763.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 916.2 999999999 794.04 967.1 case rate "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64491_1 CDM 320 RC 64491 HCPCS outpatient 1018 763.5 AETNA MCR ADV AETNA MCR ADV 794.04 78 999999999 794.04 967.1 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64491_1 CDM 320 RC 64491 HCPCS outpatient 1018 763.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 891.46 87.57 999999999 794.04 967.1 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64491_1 CDM 320 RC 64491 HCPCS outpatient 1018 763.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 866.01 85.07 999999999 794.04 967.1 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64491_1 CDM 320 RC 64491 HCPCS outpatient 1018 763.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 866.01 85.07 999999999 794.04 967.1 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64491_1 CDM 320 RC 64491 HCPCS outpatient 1018 763.5 MOLINA MCAID MOLINA MCAID 849.01 83.4 999999999 794.04 967.1 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64491_1 CDM 320 RC 64491 HCPCS outpatient 1018 763.5 MOLINA MCR ADV MOLINA MCR ADV 906.02 89 999999999 794.04 967.1 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64491_1 CDM 320 RC 64491 HCPCS outpatient 1018 763.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 906.02 89 999999999 794.04 967.1 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64491_1 CDM 320 RC 64491 HCPCS outpatient 1018 763.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 906.02 89 999999999 794.04 967.1 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64491_1 CDM 320 RC 64491 HCPCS outpatient 1018 763.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 916.2 90 999999999 794.04 967.1 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64491_1 CDM 320 RC 64491 HCPCS outpatient 1018 763.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 967.1 95 999999999 794.04 967.1 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64491_1 CDM 320 RC 64491 HCPCS outpatient 1018 763.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 967.1 95 999999999 794.04 967.1 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64491_1 CDM 320 RC 64491 HCPCS outpatient 1018 763.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 906.02 89 999999999 794.04 967.1 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64491_1 CDM 320 RC 64491 HCPCS outpatient 1018 763.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 895.84 88 999999999 794.04 967.1 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64491_1 CDM 320 RC 64491 HCPCS outpatient 1018 763.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 906.02 89 999999999 794.04 967.1 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64492_1 CDM 320 RC 64492 HCPCS outpatient 581 435.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 522.9 999999999 453.18 551.95 case rate "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64492_1 CDM 320 RC 64492 HCPCS outpatient 581 435.75 AETNA MCR ADV AETNA MCR ADV 453.18 78 999999999 453.18 551.95 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64492_1 CDM 320 RC 64492 HCPCS outpatient 581 435.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 508.78 87.57 999999999 453.18 551.95 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64492_1 CDM 320 RC 64492 HCPCS outpatient 581 435.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 494.26 85.07 999999999 453.18 551.95 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64492_1 CDM 320 RC 64492 HCPCS outpatient 581 435.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 494.26 85.07 999999999 453.18 551.95 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64492_1 CDM 320 RC 64492 HCPCS outpatient 581 435.75 MOLINA MCAID MOLINA MCAID 484.55 83.4 999999999 453.18 551.95 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64492_1 CDM 320 RC 64492 HCPCS outpatient 581 435.75 MOLINA MCR ADV MOLINA MCR ADV 517.09 89 999999999 453.18 551.95 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64492_1 CDM 320 RC 64492 HCPCS outpatient 581 435.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 517.09 89 999999999 453.18 551.95 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64492_1 CDM 320 RC 64492 HCPCS outpatient 581 435.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 517.09 89 999999999 453.18 551.95 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64492_1 CDM 320 RC 64492 HCPCS outpatient 581 435.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 522.9 90 999999999 453.18 551.95 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64492_1 CDM 320 RC 64492 HCPCS outpatient 581 435.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 551.95 95 999999999 453.18 551.95 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64492_1 CDM 320 RC 64492 HCPCS outpatient 581 435.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 551.95 95 999999999 453.18 551.95 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64492_1 CDM 320 RC 64492 HCPCS outpatient 581 435.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 517.09 89 999999999 453.18 551.95 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64492_1 CDM 320 RC 64492 HCPCS outpatient 581 435.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 511.28 88 999999999 453.18 551.95 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64492_1 CDM 320 RC 64492 HCPCS outpatient 581 435.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 517.09 89 999999999 453.18 551.95 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_1 CDM 320 RC 64493 HCPCS outpatient 2141 1605.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1926.9 999999999 1669.98 2033.95 case rate "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_1 CDM 320 RC 64493 HCPCS outpatient 2141 1605.75 AETNA MCR ADV AETNA MCR ADV 1669.98 78 999999999 1669.98 2033.95 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_1 CDM 320 RC 64493 HCPCS outpatient 2141 1605.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1874.87 87.57 999999999 1669.98 2033.95 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_1 CDM 320 RC 64493 HCPCS outpatient 2141 1605.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 1821.35 85.07 999999999 1669.98 2033.95 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_1 CDM 320 RC 64493 HCPCS outpatient 2141 1605.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1821.35 85.07 999999999 1669.98 2033.95 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_1 CDM 320 RC 64493 HCPCS outpatient 2141 1605.75 MOLINA MCAID MOLINA MCAID 1785.59 83.4 999999999 1669.98 2033.95 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_1 CDM 320 RC 64493 HCPCS outpatient 2141 1605.75 MOLINA MCR ADV MOLINA MCR ADV 1905.49 89 999999999 1669.98 2033.95 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_1 CDM 320 RC 64493 HCPCS outpatient 2141 1605.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1905.49 89 999999999 1669.98 2033.95 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_1 CDM 320 RC 64493 HCPCS outpatient 2141 1605.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1905.49 89 999999999 1669.98 2033.95 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_1 CDM 320 RC 64493 HCPCS outpatient 2141 1605.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1926.9 90 999999999 1669.98 2033.95 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_1 CDM 320 RC 64493 HCPCS outpatient 2141 1605.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 2033.95 95 999999999 1669.98 2033.95 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_1 CDM 320 RC 64493 HCPCS outpatient 2141 1605.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 2033.95 95 999999999 1669.98 2033.95 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_1 CDM 320 RC 64493 HCPCS outpatient 2141 1605.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1905.49 89 999999999 1669.98 2033.95 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_1 CDM 320 RC 64493 HCPCS outpatient 2141 1605.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1884.08 88 999999999 1669.98 2033.95 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_1 CDM 320 RC 64493 HCPCS outpatient 2141 1605.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1905.49 89 999999999 1669.98 2033.95 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_50 CDM 320 RC 64493 HCPCS inpatient 1732 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_50 CDM 320 RC 64493 HCPCS inpatient 1732 AETNA MCR ADV AETNA MCR ADV 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_50 CDM 320 RC 64493 HCPCS inpatient 1732 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_50 CDM 320 RC 64493 HCPCS inpatient 1732 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_50 CDM 320 RC 64493 HCPCS inpatient 1732 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_50 CDM 320 RC 64493 HCPCS inpatient 1732 MOLINA MCAID MOLINA MCAID 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_50 CDM 320 RC 64493 HCPCS inpatient 1732 MOLINA MCR ADV MOLINA MCR ADV 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_50 CDM 320 RC 64493 HCPCS inpatient 1732 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_50 CDM 320 RC 64493 HCPCS inpatient 1732 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_50 CDM 320 RC 64493 HCPCS inpatient 1732 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_50 CDM 320 RC 64493 HCPCS inpatient 1732 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_50 CDM 320 RC 64493 HCPCS inpatient 1732 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_50 CDM 320 RC 64493 HCPCS inpatient 1732 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_50 CDM 320 RC 64493 HCPCS inpatient 1732 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_50 CDM 320 RC 64493 HCPCS inpatient 1732 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_50_1 CDM 320 RC 64493 HCPCS outpatient 1732 1299 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 1558.8 999999999 1350.96 1645.4 case rate "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_50_1 CDM 320 RC 64493 HCPCS outpatient 1732 1299 AETNA MCR ADV AETNA MCR ADV 50 1350.96 78 999999999 1350.96 1645.4 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_50_1 CDM 320 RC 64493 HCPCS outpatient 1732 1299 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 1516.71 87.57 999999999 1350.96 1645.4 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_50_1 CDM 320 RC 64493 HCPCS outpatient 1732 1299 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 1473.41 85.07 999999999 1350.96 1645.4 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_50_1 CDM 320 RC 64493 HCPCS outpatient 1732 1299 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 1473.41 85.07 999999999 1350.96 1645.4 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_50_1 CDM 320 RC 64493 HCPCS outpatient 1732 1299 MOLINA MCAID MOLINA MCAID 50 1444.49 83.4 999999999 1350.96 1645.4 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_50_1 CDM 320 RC 64493 HCPCS outpatient 1732 1299 MOLINA MCR ADV MOLINA MCR ADV 50 1541.48 89 999999999 1350.96 1645.4 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_50_1 CDM 320 RC 64493 HCPCS outpatient 1732 1299 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 1541.48 89 999999999 1350.96 1645.4 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_50_1 CDM 320 RC 64493 HCPCS outpatient 1732 1299 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 1541.48 89 999999999 1350.96 1645.4 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_50_1 CDM 320 RC 64493 HCPCS outpatient 1732 1299 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 1558.8 90 999999999 1350.96 1645.4 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_50_1 CDM 320 RC 64493 HCPCS outpatient 1732 1299 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 1645.4 95 999999999 1350.96 1645.4 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_50_1 CDM 320 RC 64493 HCPCS outpatient 1732 1299 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 1645.4 95 999999999 1350.96 1645.4 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_50_1 CDM 320 RC 64493 HCPCS outpatient 1732 1299 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 1541.48 89 999999999 1350.96 1645.4 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_50_1 CDM 320 RC 64493 HCPCS outpatient 1732 1299 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 1524.16 88 999999999 1350.96 1645.4 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL" 64493_50_1 CDM 320 RC 64493 HCPCS outpatient 1732 1299 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 1541.48 89 999999999 1350.96 1645.4 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_1 CDM 320 RC 64494 HCPCS outpatient 959 719.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 863.1 999999999 748.02 911.05 case rate "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_1 CDM 320 RC 64494 HCPCS outpatient 959 719.25 AETNA MCR ADV AETNA MCR ADV 748.02 78 999999999 748.02 911.05 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_1 CDM 320 RC 64494 HCPCS outpatient 959 719.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 839.8 87.57 999999999 748.02 911.05 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_1 CDM 320 RC 64494 HCPCS outpatient 959 719.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 815.82 85.07 999999999 748.02 911.05 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_1 CDM 320 RC 64494 HCPCS outpatient 959 719.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 815.82 85.07 999999999 748.02 911.05 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_1 CDM 320 RC 64494 HCPCS outpatient 959 719.25 MOLINA MCAID MOLINA MCAID 799.81 83.4 999999999 748.02 911.05 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_1 CDM 320 RC 64494 HCPCS outpatient 959 719.25 MOLINA MCR ADV MOLINA MCR ADV 853.51 89 999999999 748.02 911.05 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_1 CDM 320 RC 64494 HCPCS outpatient 959 719.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 853.51 89 999999999 748.02 911.05 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_1 CDM 320 RC 64494 HCPCS outpatient 959 719.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 853.51 89 999999999 748.02 911.05 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_1 CDM 320 RC 64494 HCPCS outpatient 959 719.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 863.1 90 999999999 748.02 911.05 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_1 CDM 320 RC 64494 HCPCS outpatient 959 719.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 911.05 95 999999999 748.02 911.05 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_1 CDM 320 RC 64494 HCPCS outpatient 959 719.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 911.05 95 999999999 748.02 911.05 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_1 CDM 320 RC 64494 HCPCS outpatient 959 719.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 853.51 89 999999999 748.02 911.05 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_1 CDM 320 RC 64494 HCPCS outpatient 959 719.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 843.92 88 999999999 748.02 911.05 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_1 CDM 320 RC 64494 HCPCS outpatient 959 719.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 853.51 89 999999999 748.02 911.05 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_50 CDM 320 RC 64494 HCPCS inpatient 864 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_50 CDM 320 RC 64494 HCPCS inpatient 864 AETNA MCR ADV AETNA MCR ADV 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_50 CDM 320 RC 64494 HCPCS inpatient 864 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_50 CDM 320 RC 64494 HCPCS inpatient 864 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_50 CDM 320 RC 64494 HCPCS inpatient 864 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_50 CDM 320 RC 64494 HCPCS inpatient 864 MOLINA MCAID MOLINA MCAID 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_50 CDM 320 RC 64494 HCPCS inpatient 864 MOLINA MCR ADV MOLINA MCR ADV 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_50 CDM 320 RC 64494 HCPCS inpatient 864 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_50 CDM 320 RC 64494 HCPCS inpatient 864 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_50 CDM 320 RC 64494 HCPCS inpatient 864 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_50 CDM 320 RC 64494 HCPCS inpatient 864 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_50 CDM 320 RC 64494 HCPCS inpatient 864 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_50 CDM 320 RC 64494 HCPCS inpatient 864 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_50 CDM 320 RC 64494 HCPCS inpatient 864 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_50 CDM 320 RC 64494 HCPCS inpatient 864 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_50_1 CDM 320 RC 64494 HCPCS outpatient 864 648 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 777.6 999999999 673.92 820.8 case rate "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_50_1 CDM 320 RC 64494 HCPCS outpatient 864 648 AETNA MCR ADV AETNA MCR ADV 50 673.92 78 999999999 673.92 820.8 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_50_1 CDM 320 RC 64494 HCPCS outpatient 864 648 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 756.6 87.57 999999999 673.92 820.8 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_50_1 CDM 320 RC 64494 HCPCS outpatient 864 648 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 735 85.07 999999999 673.92 820.8 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_50_1 CDM 320 RC 64494 HCPCS outpatient 864 648 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 735 85.07 999999999 673.92 820.8 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_50_1 CDM 320 RC 64494 HCPCS outpatient 864 648 MOLINA MCAID MOLINA MCAID 50 720.58 83.4 999999999 673.92 820.8 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_50_1 CDM 320 RC 64494 HCPCS outpatient 864 648 MOLINA MCR ADV MOLINA MCR ADV 50 768.96 89 999999999 673.92 820.8 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_50_1 CDM 320 RC 64494 HCPCS outpatient 864 648 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 768.96 89 999999999 673.92 820.8 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_50_1 CDM 320 RC 64494 HCPCS outpatient 864 648 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 768.96 89 999999999 673.92 820.8 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_50_1 CDM 320 RC 64494 HCPCS outpatient 864 648 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 777.6 90 999999999 673.92 820.8 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_50_1 CDM 320 RC 64494 HCPCS outpatient 864 648 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 820.8 95 999999999 673.92 820.8 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_50_1 CDM 320 RC 64494 HCPCS outpatient 864 648 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 820.8 95 999999999 673.92 820.8 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_50_1 CDM 320 RC 64494 HCPCS outpatient 864 648 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 768.96 89 999999999 673.92 820.8 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_50_1 CDM 320 RC 64494 HCPCS outpatient 864 648 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 760.32 88 999999999 673.92 820.8 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64494_50_1 CDM 320 RC 64494 HCPCS outpatient 864 648 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 768.96 89 999999999 673.92 820.8 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_1 CDM 320 RC 64495 HCPCS outpatient 578 433.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 520.2 999999999 450.84 549.1 case rate "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_1 CDM 320 RC 64495 HCPCS outpatient 578 433.5 AETNA MCR ADV AETNA MCR ADV 450.84 78 999999999 450.84 549.1 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_1 CDM 320 RC 64495 HCPCS outpatient 578 433.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 506.15 87.57 999999999 450.84 549.1 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_1 CDM 320 RC 64495 HCPCS outpatient 578 433.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 491.7 85.07 999999999 450.84 549.1 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_1 CDM 320 RC 64495 HCPCS outpatient 578 433.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 491.7 85.07 999999999 450.84 549.1 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_1 CDM 320 RC 64495 HCPCS outpatient 578 433.5 MOLINA MCAID MOLINA MCAID 482.05 83.4 999999999 450.84 549.1 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_1 CDM 320 RC 64495 HCPCS outpatient 578 433.5 MOLINA MCR ADV MOLINA MCR ADV 514.42 89 999999999 450.84 549.1 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_1 CDM 320 RC 64495 HCPCS outpatient 578 433.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 514.42 89 999999999 450.84 549.1 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_1 CDM 320 RC 64495 HCPCS outpatient 578 433.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 514.42 89 999999999 450.84 549.1 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_1 CDM 320 RC 64495 HCPCS outpatient 578 433.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 520.2 90 999999999 450.84 549.1 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_1 CDM 320 RC 64495 HCPCS outpatient 578 433.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 549.1 95 999999999 450.84 549.1 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_1 CDM 320 RC 64495 HCPCS outpatient 578 433.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 549.1 95 999999999 450.84 549.1 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_1 CDM 320 RC 64495 HCPCS outpatient 578 433.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 514.42 89 999999999 450.84 549.1 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_1 CDM 320 RC 64495 HCPCS outpatient 578 433.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 508.64 88 999999999 450.84 549.1 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_1 CDM 320 RC 64495 HCPCS outpatient 578 433.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 514.42 89 999999999 450.84 549.1 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_50 CDM 320 RC 64495 HCPCS inpatient 864 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_50 CDM 320 RC 64495 HCPCS inpatient 864 AETNA MCR ADV AETNA MCR ADV 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_50 CDM 320 RC 64495 HCPCS inpatient 864 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_50 CDM 320 RC 64495 HCPCS inpatient 864 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_50 CDM 320 RC 64495 HCPCS inpatient 864 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_50 CDM 320 RC 64495 HCPCS inpatient 864 MOLINA MCAID MOLINA MCAID 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_50 CDM 320 RC 64495 HCPCS inpatient 864 MOLINA MCR ADV MOLINA MCR ADV 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_50 CDM 320 RC 64495 HCPCS inpatient 864 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_50 CDM 320 RC 64495 HCPCS inpatient 864 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_50 CDM 320 RC 64495 HCPCS inpatient 864 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_50 CDM 320 RC 64495 HCPCS inpatient 864 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_50 CDM 320 RC 64495 HCPCS inpatient 864 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_50 CDM 320 RC 64495 HCPCS inpatient 864 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_50 CDM 320 RC 64495 HCPCS inpatient 864 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_50 CDM 320 RC 64495 HCPCS inpatient 864 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 999999999 "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_50_1 CDM 320 RC 64495 HCPCS outpatient 864 648 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 777.6 999999999 673.92 820.8 case rate "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_50_1 CDM 320 RC 64495 HCPCS outpatient 864 648 AETNA MCR ADV AETNA MCR ADV 50 673.92 78 999999999 673.92 820.8 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_50_1 CDM 320 RC 64495 HCPCS outpatient 864 648 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 756.6 87.57 999999999 673.92 820.8 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_50_1 CDM 320 RC 64495 HCPCS outpatient 864 648 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 735 85.07 999999999 673.92 820.8 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_50_1 CDM 320 RC 64495 HCPCS outpatient 864 648 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 735 85.07 999999999 673.92 820.8 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_50_1 CDM 320 RC 64495 HCPCS outpatient 864 648 MOLINA MCAID MOLINA MCAID 50 720.58 83.4 999999999 673.92 820.8 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_50_1 CDM 320 RC 64495 HCPCS outpatient 864 648 MOLINA MCR ADV MOLINA MCR ADV 50 768.96 89 999999999 673.92 820.8 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_50_1 CDM 320 RC 64495 HCPCS outpatient 864 648 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 768.96 89 999999999 673.92 820.8 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_50_1 CDM 320 RC 64495 HCPCS outpatient 864 648 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 768.96 89 999999999 673.92 820.8 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_50_1 CDM 320 RC 64495 HCPCS outpatient 864 648 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 777.6 90 999999999 673.92 820.8 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_50_1 CDM 320 RC 64495 HCPCS outpatient 864 648 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 820.8 95 999999999 673.92 820.8 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_50_1 CDM 320 RC 64495 HCPCS outpatient 864 648 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 820.8 95 999999999 673.92 820.8 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_50_1 CDM 320 RC 64495 HCPCS outpatient 864 648 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 768.96 89 999999999 673.92 820.8 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_50_1 CDM 320 RC 64495 HCPCS outpatient 864 648 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 760.32 88 999999999 673.92 820.8 percent of total billed charges "INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64495_50_1 CDM 320 RC 64495 HCPCS outpatient 864 648 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 768.96 89 999999999 673.92 820.8 percent of total billed charges "INJECTION, ANESTHETIC AGENT; SPHENOPALATINE GANGLION" 64505_1 CDM 360 RC 64505 HCPCS outpatient 648 486 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 615.6 95 999999999 505.44 615.6 percent of total billed charges "INJECTION, ANESTHETIC AGENT; SPHENOPALATINE GANGLION" 64505_1 CDM 360 RC 64505 HCPCS outpatient 648 486 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 615.6 95 999999999 505.44 615.6 percent of total billed charges "INJECTION, ANESTHETIC AGENT; SPHENOPALATINE GANGLION" 64505_1 CDM 360 RC 64505 HCPCS outpatient 648 486 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 576.72 89 999999999 505.44 615.6 percent of total billed charges "INJECTION, ANESTHETIC AGENT; SPHENOPALATINE GANGLION" 64505_1 CDM 360 RC 64505 HCPCS outpatient 648 486 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 570.24 88 999999999 505.44 615.6 percent of total billed charges "INJECTION, ANESTHETIC AGENT; SPHENOPALATINE GANGLION" 64505_1 CDM 360 RC 64505 HCPCS outpatient 648 486 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 576.72 89 999999999 505.44 615.6 percent of total billed charges "INJECTION, ANESTHETIC AGENT; SPHENOPALATINE GANGLION" 64505_1 CDM 360 RC 64505 HCPCS outpatient 648 486 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 583.2 999999999 505.44 615.6 case rate "INJECTION, ANESTHETIC AGENT; SPHENOPALATINE GANGLION" 64505_1 CDM 360 RC 64505 HCPCS outpatient 648 486 AETNA MCR ADV AETNA MCR ADV 505.44 78 999999999 505.44 615.6 percent of total billed charges "INJECTION, ANESTHETIC AGENT; SPHENOPALATINE GANGLION" 64505_1 CDM 360 RC 64505 HCPCS outpatient 648 486 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 567.45 87.57 999999999 505.44 615.6 percent of total billed charges "INJECTION, ANESTHETIC AGENT; SPHENOPALATINE GANGLION" 64505_1 CDM 360 RC 64505 HCPCS outpatient 648 486 COORDINATED CARE MCAID COORDINATED CARE MCAID 551.25 85.07 999999999 505.44 615.6 percent of total billed charges "INJECTION, ANESTHETIC AGENT; SPHENOPALATINE GANGLION" 64505_1 CDM 360 RC 64505 HCPCS outpatient 648 486 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 551.25 85.07 999999999 505.44 615.6 percent of total billed charges "INJECTION, ANESTHETIC AGENT; SPHENOPALATINE GANGLION" 64505_1 CDM 360 RC 64505 HCPCS outpatient 648 486 MOLINA MCAID MOLINA MCAID 540.43 83.4 999999999 505.44 615.6 percent of total billed charges "INJECTION, ANESTHETIC AGENT; SPHENOPALATINE GANGLION" 64505_1 CDM 360 RC 64505 HCPCS outpatient 648 486 MOLINA MCR ADV MOLINA MCR ADV 576.72 89 999999999 505.44 615.6 percent of total billed charges "INJECTION, ANESTHETIC AGENT; SPHENOPALATINE GANGLION" 64505_1 CDM 360 RC 64505 HCPCS outpatient 648 486 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 576.72 89 999999999 505.44 615.6 percent of total billed charges "INJECTION, ANESTHETIC AGENT; SPHENOPALATINE GANGLION" 64505_1 CDM 360 RC 64505 HCPCS outpatient 648 486 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 576.72 89 999999999 505.44 615.6 percent of total billed charges "INJECTION, ANESTHETIC AGENT; SPHENOPALATINE GANGLION" 64505_1 CDM 360 RC 64505 HCPCS outpatient 648 486 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 583.2 90 999999999 505.44 615.6 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_1 CDM 960 RC 64624 HCPCS outpatient 2795 2096.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 558.15 999999999 199.25 2934.75 fee schedule "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_1 CDM 960 RC 64624 HCPCS outpatient 2795 2096.25 AETNA MCR ADV AETNA MCR ADV 2795 999999999 199.25 2934.75 fee schedule "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_1 CDM 960 RC 64624 HCPCS outpatient 2795 2096.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 2934.75 999999999 199.25 2934.75 fee schedule "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_1 CDM 960 RC 64624 HCPCS outpatient 2795 2096.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 2795 999999999 199.25 2934.75 fee schedule "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_1 CDM 960 RC 64624 HCPCS outpatient 2795 2096.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 2795 999999999 199.25 2934.75 fee schedule "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_1 CDM 960 RC 64624 HCPCS outpatient 2795 2096.25 MOLINA MCAID MOLINA MCAID 2934.75 999999999 199.25 2934.75 fee schedule "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_1 CDM 960 RC 64624 HCPCS outpatient 2795 2096.25 MOLINA MCR ADV MOLINA MCR ADV 2795 999999999 199.25 2934.75 fee schedule "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_1 CDM 960 RC 64624 HCPCS outpatient 2795 2096.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 2795 999999999 199.25 2934.75 fee schedule "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_1 CDM 960 RC 64624 HCPCS outpatient 2795 2096.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 2795 999999999 199.25 2934.75 fee schedule "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_1 CDM 960 RC 64624 HCPCS outpatient 2795 2096.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 555.37 999999999 199.25 2934.75 fee schedule "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_1 CDM 960 RC 64624 HCPCS outpatient 2795 2096.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 999999999 199.25 2934.75 fee schedule "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_1 CDM 960 RC 64624 HCPCS outpatient 2795 2096.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 999999999 199.25 2934.75 fee schedule "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_1 CDM 960 RC 64624 HCPCS outpatient 2795 2096.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 2795 999999999 199.25 2934.75 fee schedule "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_1 CDM 960 RC 64624 HCPCS outpatient 2795 2096.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 199.25 999999999 199.25 2934.75 fee schedule "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_1 CDM 960 RC 64624 HCPCS outpatient 2795 2096.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 2795 999999999 199.25 2934.75 fee schedule "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_50 CDM 960 RC 64624 HCPCS inpatient 4193 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_50 CDM 960 RC 64624 HCPCS inpatient 4193 AETNA MCR ADV AETNA MCR ADV 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_50 CDM 960 RC 64624 HCPCS inpatient 4193 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_50 CDM 960 RC 64624 HCPCS inpatient 4193 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_50 CDM 960 RC 64624 HCPCS inpatient 4193 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_50 CDM 960 RC 64624 HCPCS inpatient 4193 MOLINA MCAID MOLINA MCAID 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_50 CDM 960 RC 64624 HCPCS inpatient 4193 MOLINA MCR ADV MOLINA MCR ADV 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_50 CDM 960 RC 64624 HCPCS inpatient 4193 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_50 CDM 960 RC 64624 HCPCS inpatient 4193 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_50 CDM 960 RC 64624 HCPCS inpatient 4193 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_50 CDM 960 RC 64624 HCPCS inpatient 4193 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_50 CDM 960 RC 64624 HCPCS inpatient 4193 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_50 CDM 960 RC 64624 HCPCS inpatient 4193 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_50 CDM 960 RC 64624 HCPCS inpatient 4193 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_50 CDM 960 RC 64624 HCPCS inpatient 4193 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_50_1 CDM 960 RC 64624 HCPCS outpatient 4193 3144.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 558.15 999999999 199.25 4402.65 fee schedule "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_50_1 CDM 960 RC 64624 HCPCS outpatient 4193 3144.75 AETNA MCR ADV AETNA MCR ADV 50 4193 999999999 199.25 4402.65 fee schedule "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_50_1 CDM 960 RC 64624 HCPCS outpatient 4193 3144.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 4402.65 999999999 199.25 4402.65 fee schedule "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_50_1 CDM 960 RC 64624 HCPCS outpatient 4193 3144.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 4193 999999999 199.25 4402.65 fee schedule "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_50_1 CDM 960 RC 64624 HCPCS outpatient 4193 3144.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 4193 999999999 199.25 4402.65 fee schedule "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_50_1 CDM 960 RC 64624 HCPCS outpatient 4193 3144.75 MOLINA MCAID MOLINA MCAID 50 4402.65 999999999 199.25 4402.65 fee schedule "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_50_1 CDM 960 RC 64624 HCPCS outpatient 4193 3144.75 MOLINA MCR ADV MOLINA MCR ADV 50 4193 999999999 199.25 4402.65 fee schedule "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_50_1 CDM 960 RC 64624 HCPCS outpatient 4193 3144.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 4193 999999999 199.25 4402.65 fee schedule "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_50_1 CDM 960 RC 64624 HCPCS outpatient 4193 3144.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 4193 999999999 199.25 4402.65 fee schedule "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_50_1 CDM 960 RC 64624 HCPCS outpatient 4193 3144.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 555.37 999999999 199.25 4402.65 fee schedule "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_50_1 CDM 960 RC 64624 HCPCS outpatient 4193 3144.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 999999999 199.25 4402.65 fee schedule "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_50_1 CDM 960 RC 64624 HCPCS outpatient 4193 3144.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 999999999 199.25 4402.65 fee schedule "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_50_1 CDM 960 RC 64624 HCPCS outpatient 4193 3144.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 4193 999999999 199.25 4402.65 fee schedule "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_50_1 CDM 960 RC 64624 HCPCS outpatient 4193 3144.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 199.25 999999999 199.25 4402.65 fee schedule "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 64624_50_1 CDM 960 RC 64624 HCPCS outpatient 4193 3144.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 4193 999999999 199.25 4402.65 fee schedule "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT" 64633_1 CDM 360 RC 64633 HCPCS outpatient 1688 1266 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1519.2 999999999 1316.64 1603.6 case rate "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT" 64633_1 CDM 360 RC 64633 HCPCS outpatient 1688 1266 AETNA MCR ADV AETNA MCR ADV 1316.64 78 999999999 1316.64 1603.6 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT" 64633_1 CDM 360 RC 64633 HCPCS outpatient 1688 1266 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1478.18 87.57 999999999 1316.64 1603.6 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT" 64633_1 CDM 360 RC 64633 HCPCS outpatient 1688 1266 COORDINATED CARE MCAID COORDINATED CARE MCAID 1435.98 85.07 999999999 1316.64 1603.6 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT" 64633_1 CDM 360 RC 64633 HCPCS outpatient 1688 1266 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1435.98 85.07 999999999 1316.64 1603.6 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT" 64633_1 CDM 360 RC 64633 HCPCS outpatient 1688 1266 MOLINA MCAID MOLINA MCAID 1407.79 83.4 999999999 1316.64 1603.6 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT" 64633_1 CDM 360 RC 64633 HCPCS outpatient 1688 1266 MOLINA MCR ADV MOLINA MCR ADV 1502.32 89 999999999 1316.64 1603.6 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT" 64633_1 CDM 360 RC 64633 HCPCS outpatient 1688 1266 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1502.32 89 999999999 1316.64 1603.6 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT" 64633_1 CDM 360 RC 64633 HCPCS outpatient 1688 1266 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1502.32 89 999999999 1316.64 1603.6 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT" 64633_1 CDM 360 RC 64633 HCPCS outpatient 1688 1266 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1519.2 90 999999999 1316.64 1603.6 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT" 64633_1 CDM 360 RC 64633 HCPCS outpatient 1688 1266 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1603.6 95 999999999 1316.64 1603.6 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT" 64633_1 CDM 360 RC 64633 HCPCS outpatient 1688 1266 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1603.6 95 999999999 1316.64 1603.6 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT" 64633_1 CDM 360 RC 64633 HCPCS outpatient 1688 1266 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1502.32 89 999999999 1316.64 1603.6 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT" 64633_1 CDM 360 RC 64633 HCPCS outpatient 1688 1266 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1485.44 88 999999999 1316.64 1603.6 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT" 64633_1 CDM 360 RC 64633 HCPCS outpatient 1688 1266 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1502.32 89 999999999 1316.64 1603.6 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64634_1 CDM 360 RC 64634 HCPCS outpatient 844 633 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 759.6 999999999 658.32 801.8 case rate "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64634_1 CDM 360 RC 64634 HCPCS outpatient 844 633 AETNA MCR ADV AETNA MCR ADV 658.32 78 999999999 658.32 801.8 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64634_1 CDM 360 RC 64634 HCPCS outpatient 844 633 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 739.09 87.57 999999999 658.32 801.8 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64634_1 CDM 360 RC 64634 HCPCS outpatient 844 633 COORDINATED CARE MCAID COORDINATED CARE MCAID 717.99 85.07 999999999 658.32 801.8 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64634_1 CDM 360 RC 64634 HCPCS outpatient 844 633 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 717.99 85.07 999999999 658.32 801.8 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64634_1 CDM 360 RC 64634 HCPCS outpatient 844 633 MOLINA MCAID MOLINA MCAID 703.9 83.4 999999999 658.32 801.8 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64634_1 CDM 360 RC 64634 HCPCS outpatient 844 633 MOLINA MCR ADV MOLINA MCR ADV 751.16 89 999999999 658.32 801.8 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64634_1 CDM 360 RC 64634 HCPCS outpatient 844 633 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 751.16 89 999999999 658.32 801.8 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64634_1 CDM 360 RC 64634 HCPCS outpatient 844 633 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 751.16 89 999999999 658.32 801.8 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64634_1 CDM 360 RC 64634 HCPCS outpatient 844 633 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 759.6 90 999999999 658.32 801.8 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64634_1 CDM 360 RC 64634 HCPCS outpatient 844 633 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 801.8 95 999999999 658.32 801.8 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64634_1 CDM 360 RC 64634 HCPCS outpatient 844 633 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 801.8 95 999999999 658.32 801.8 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64634_1 CDM 360 RC 64634 HCPCS outpatient 844 633 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 751.16 89 999999999 658.32 801.8 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64634_1 CDM 360 RC 64634 HCPCS outpatient 844 633 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 742.72 88 999999999 658.32 801.8 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64634_1 CDM 360 RC 64634 HCPCS outpatient 844 633 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 751.16 89 999999999 658.32 801.8 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_1 CDM 360 RC 64635 HCPCS outpatient 1742 1306.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1567.8 999999999 1358.76 1654.9 case rate "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_1 CDM 360 RC 64635 HCPCS outpatient 1742 1306.5 AETNA MCR ADV AETNA MCR ADV 1358.76 78 999999999 1358.76 1654.9 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_1 CDM 360 RC 64635 HCPCS outpatient 1742 1306.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1525.47 87.57 999999999 1358.76 1654.9 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_1 CDM 360 RC 64635 HCPCS outpatient 1742 1306.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 1481.92 85.07 999999999 1358.76 1654.9 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_1 CDM 360 RC 64635 HCPCS outpatient 1742 1306.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1481.92 85.07 999999999 1358.76 1654.9 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_1 CDM 360 RC 64635 HCPCS outpatient 1742 1306.5 MOLINA MCAID MOLINA MCAID 1452.83 83.4 999999999 1358.76 1654.9 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_1 CDM 360 RC 64635 HCPCS outpatient 1742 1306.5 MOLINA MCR ADV MOLINA MCR ADV 1550.38 89 999999999 1358.76 1654.9 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_1 CDM 360 RC 64635 HCPCS outpatient 1742 1306.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1550.38 89 999999999 1358.76 1654.9 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_1 CDM 360 RC 64635 HCPCS outpatient 1742 1306.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1550.38 89 999999999 1358.76 1654.9 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_1 CDM 360 RC 64635 HCPCS outpatient 1742 1306.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1567.8 90 999999999 1358.76 1654.9 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_1 CDM 360 RC 64635 HCPCS outpatient 1742 1306.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1654.9 95 999999999 1358.76 1654.9 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_1 CDM 360 RC 64635 HCPCS outpatient 1742 1306.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1654.9 95 999999999 1358.76 1654.9 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_1 CDM 360 RC 64635 HCPCS outpatient 1742 1306.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1550.38 89 999999999 1358.76 1654.9 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_1 CDM 360 RC 64635 HCPCS outpatient 1742 1306.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1532.96 88 999999999 1358.76 1654.9 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_1 CDM 360 RC 64635 HCPCS outpatient 1742 1306.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1550.38 89 999999999 1358.76 1654.9 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_50 CDM 360 RC 64635 HCPCS inpatient 2614 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_50 CDM 360 RC 64635 HCPCS inpatient 2614 AETNA MCR ADV AETNA MCR ADV 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_50 CDM 360 RC 64635 HCPCS inpatient 2614 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_50 CDM 360 RC 64635 HCPCS inpatient 2614 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_50 CDM 360 RC 64635 HCPCS inpatient 2614 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_50 CDM 360 RC 64635 HCPCS inpatient 2614 MOLINA MCAID MOLINA MCAID 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_50 CDM 360 RC 64635 HCPCS inpatient 2614 MOLINA MCR ADV MOLINA MCR ADV 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_50 CDM 360 RC 64635 HCPCS inpatient 2614 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_50 CDM 360 RC 64635 HCPCS inpatient 2614 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_50 CDM 360 RC 64635 HCPCS inpatient 2614 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_50 CDM 360 RC 64635 HCPCS inpatient 2614 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_50 CDM 360 RC 64635 HCPCS inpatient 2614 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_50 CDM 360 RC 64635 HCPCS inpatient 2614 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_50 CDM 360 RC 64635 HCPCS inpatient 2614 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_50 CDM 360 RC 64635 HCPCS inpatient 2614 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_50_1 CDM 360 RC 64635 HCPCS outpatient 2614 1960.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 2352.6 999999999 2038.92 2483.3 case rate "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_50_1 CDM 360 RC 64635 HCPCS outpatient 2614 1960.5 AETNA MCR ADV AETNA MCR ADV 50 2038.92 78 999999999 2038.92 2483.3 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_50_1 CDM 360 RC 64635 HCPCS outpatient 2614 1960.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 2289.08 87.57 999999999 2038.92 2483.3 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_50_1 CDM 360 RC 64635 HCPCS outpatient 2614 1960.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 2223.73 85.07 999999999 2038.92 2483.3 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_50_1 CDM 360 RC 64635 HCPCS outpatient 2614 1960.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 2223.73 85.07 999999999 2038.92 2483.3 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_50_1 CDM 360 RC 64635 HCPCS outpatient 2614 1960.5 MOLINA MCAID MOLINA MCAID 50 2180.08 83.4 999999999 2038.92 2483.3 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_50_1 CDM 360 RC 64635 HCPCS outpatient 2614 1960.5 MOLINA MCR ADV MOLINA MCR ADV 50 2326.46 89 999999999 2038.92 2483.3 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_50_1 CDM 360 RC 64635 HCPCS outpatient 2614 1960.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 2326.46 89 999999999 2038.92 2483.3 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_50_1 CDM 360 RC 64635 HCPCS outpatient 2614 1960.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 2326.46 89 999999999 2038.92 2483.3 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_50_1 CDM 360 RC 64635 HCPCS outpatient 2614 1960.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 2352.6 90 999999999 2038.92 2483.3 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_50_1 CDM 360 RC 64635 HCPCS outpatient 2614 1960.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 2483.3 95 999999999 2038.92 2483.3 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_50_1 CDM 360 RC 64635 HCPCS outpatient 2614 1960.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 2483.3 95 999999999 2038.92 2483.3 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_50_1 CDM 360 RC 64635 HCPCS outpatient 2614 1960.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 2326.46 89 999999999 2038.92 2483.3 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_50_1 CDM 360 RC 64635 HCPCS outpatient 2614 1960.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 2300.32 88 999999999 2038.92 2483.3 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 64635_50_1 CDM 360 RC 64635 HCPCS outpatient 2614 1960.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 2326.46 89 999999999 2038.92 2483.3 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_1 CDM 360 RC 64636 HCPCS outpatient 870 652.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 783 999999999 678.6 826.5 case rate "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_1 CDM 360 RC 64636 HCPCS outpatient 870 652.5 AETNA MCR ADV AETNA MCR ADV 678.6 78 999999999 678.6 826.5 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_1 CDM 360 RC 64636 HCPCS outpatient 870 652.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 761.86 87.57 999999999 678.6 826.5 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_1 CDM 360 RC 64636 HCPCS outpatient 870 652.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 740.11 85.07 999999999 678.6 826.5 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_1 CDM 360 RC 64636 HCPCS outpatient 870 652.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 740.11 85.07 999999999 678.6 826.5 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_1 CDM 360 RC 64636 HCPCS outpatient 870 652.5 MOLINA MCAID MOLINA MCAID 725.58 83.4 999999999 678.6 826.5 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_1 CDM 360 RC 64636 HCPCS outpatient 870 652.5 MOLINA MCR ADV MOLINA MCR ADV 774.3 89 999999999 678.6 826.5 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_1 CDM 360 RC 64636 HCPCS outpatient 870 652.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 774.3 89 999999999 678.6 826.5 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_1 CDM 360 RC 64636 HCPCS outpatient 870 652.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 774.3 89 999999999 678.6 826.5 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_1 CDM 360 RC 64636 HCPCS outpatient 870 652.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 783 90 999999999 678.6 826.5 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_1 CDM 360 RC 64636 HCPCS outpatient 870 652.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 826.5 95 999999999 678.6 826.5 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_1 CDM 360 RC 64636 HCPCS outpatient 870 652.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 826.5 95 999999999 678.6 826.5 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_1 CDM 360 RC 64636 HCPCS outpatient 870 652.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 774.3 89 999999999 678.6 826.5 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_1 CDM 360 RC 64636 HCPCS outpatient 870 652.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 765.6 88 999999999 678.6 826.5 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_1 CDM 360 RC 64636 HCPCS outpatient 870 652.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 774.3 89 999999999 678.6 826.5 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_50 CDM 360 RC 64636 HCPCS inpatient 1296 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_50 CDM 360 RC 64636 HCPCS inpatient 1296 AETNA MCR ADV AETNA MCR ADV 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_50 CDM 360 RC 64636 HCPCS inpatient 1296 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_50 CDM 360 RC 64636 HCPCS inpatient 1296 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_50 CDM 360 RC 64636 HCPCS inpatient 1296 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_50 CDM 360 RC 64636 HCPCS inpatient 1296 MOLINA MCAID MOLINA MCAID 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_50 CDM 360 RC 64636 HCPCS inpatient 1296 MOLINA MCR ADV MOLINA MCR ADV 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_50 CDM 360 RC 64636 HCPCS inpatient 1296 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_50 CDM 360 RC 64636 HCPCS inpatient 1296 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_50 CDM 360 RC 64636 HCPCS inpatient 1296 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_50 CDM 360 RC 64636 HCPCS inpatient 1296 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_50 CDM 360 RC 64636 HCPCS inpatient 1296 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_50 CDM 360 RC 64636 HCPCS inpatient 1296 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_50 CDM 360 RC 64636 HCPCS inpatient 1296 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_50 CDM 360 RC 64636 HCPCS inpatient 1296 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_50_1 CDM 360 RC 64636 HCPCS outpatient 1296 972 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 1166.4 999999999 1010.88 1231.2 case rate "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_50_1 CDM 360 RC 64636 HCPCS outpatient 1296 972 AETNA MCR ADV AETNA MCR ADV 50 1010.88 78 999999999 1010.88 1231.2 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_50_1 CDM 360 RC 64636 HCPCS outpatient 1296 972 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 1134.91 87.57 999999999 1010.88 1231.2 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_50_1 CDM 360 RC 64636 HCPCS outpatient 1296 972 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 1102.51 85.07 999999999 1010.88 1231.2 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_50_1 CDM 360 RC 64636 HCPCS outpatient 1296 972 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 1102.51 85.07 999999999 1010.88 1231.2 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_50_1 CDM 360 RC 64636 HCPCS outpatient 1296 972 MOLINA MCAID MOLINA MCAID 50 1080.86 83.4 999999999 1010.88 1231.2 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_50_1 CDM 360 RC 64636 HCPCS outpatient 1296 972 MOLINA MCR ADV MOLINA MCR ADV 50 1153.44 89 999999999 1010.88 1231.2 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_50_1 CDM 360 RC 64636 HCPCS outpatient 1296 972 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 1153.44 89 999999999 1010.88 1231.2 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_50_1 CDM 360 RC 64636 HCPCS outpatient 1296 972 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 1153.44 89 999999999 1010.88 1231.2 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_50_1 CDM 360 RC 64636 HCPCS outpatient 1296 972 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 1166.4 90 999999999 1010.88 1231.2 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_50_1 CDM 360 RC 64636 HCPCS outpatient 1296 972 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 1231.2 95 999999999 1010.88 1231.2 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_50_1 CDM 360 RC 64636 HCPCS outpatient 1296 972 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 1231.2 95 999999999 1010.88 1231.2 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_50_1 CDM 360 RC 64636 HCPCS outpatient 1296 972 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 1153.44 89 999999999 1010.88 1231.2 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_50_1 CDM 360 RC 64636 HCPCS outpatient 1296 972 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 1140.48 88 999999999 1010.88 1231.2 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 64636_50_1 CDM 360 RC 64636 HCPCS outpatient 1296 972 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 1153.44 89 999999999 1010.88 1231.2 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 64640_1 CDM 360 RC 64640 HCPCS outpatient 1742 1306.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1567.8 999999999 1358.76 1654.9 case rate DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 64640_1 CDM 360 RC 64640 HCPCS outpatient 1742 1306.5 AETNA MCR ADV AETNA MCR ADV 1358.76 78 999999999 1358.76 1654.9 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 64640_1 CDM 360 RC 64640 HCPCS outpatient 1742 1306.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1525.47 87.57 999999999 1358.76 1654.9 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 64640_1 CDM 360 RC 64640 HCPCS outpatient 1742 1306.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 1481.92 85.07 999999999 1358.76 1654.9 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 64640_1 CDM 360 RC 64640 HCPCS outpatient 1742 1306.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1481.92 85.07 999999999 1358.76 1654.9 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 64640_1 CDM 360 RC 64640 HCPCS outpatient 1742 1306.5 MOLINA MCAID MOLINA MCAID 1452.83 83.4 999999999 1358.76 1654.9 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 64640_1 CDM 360 RC 64640 HCPCS outpatient 1742 1306.5 MOLINA MCR ADV MOLINA MCR ADV 1550.38 89 999999999 1358.76 1654.9 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 64640_1 CDM 360 RC 64640 HCPCS outpatient 1742 1306.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1550.38 89 999999999 1358.76 1654.9 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 64640_1 CDM 360 RC 64640 HCPCS outpatient 1742 1306.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1550.38 89 999999999 1358.76 1654.9 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 64640_1 CDM 360 RC 64640 HCPCS outpatient 1742 1306.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1567.8 90 999999999 1358.76 1654.9 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 64640_1 CDM 360 RC 64640 HCPCS outpatient 1742 1306.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1654.9 95 999999999 1358.76 1654.9 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 64640_1 CDM 360 RC 64640 HCPCS outpatient 1742 1306.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1654.9 95 999999999 1358.76 1654.9 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 64640_1 CDM 360 RC 64640 HCPCS outpatient 1742 1306.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1550.38 89 999999999 1358.76 1654.9 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 64640_1 CDM 360 RC 64640 HCPCS outpatient 1742 1306.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1532.96 88 999999999 1358.76 1654.9 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 64640_1 CDM 360 RC 64640 HCPCS outpatient 1742 1306.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1550.38 89 999999999 1358.76 1654.9 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 64640_50_1 CDM 360 RC 64640 HCPCS outpatient 2614 1960.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 2352.6 999999999 2038.92 2483.3 case rate DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 64640_50_1 CDM 360 RC 64640 HCPCS outpatient 2614 1960.5 AETNA MCR ADV AETNA MCR ADV 50 2038.92 78 999999999 2038.92 2483.3 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 64640_50_1 CDM 360 RC 64640 HCPCS outpatient 2614 1960.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 2289.08 87.57 999999999 2038.92 2483.3 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 64640_50_1 CDM 360 RC 64640 HCPCS outpatient 2614 1960.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 2223.73 85.07 999999999 2038.92 2483.3 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 64640_50_1 CDM 360 RC 64640 HCPCS outpatient 2614 1960.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 2223.73 85.07 999999999 2038.92 2483.3 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 64640_50_1 CDM 360 RC 64640 HCPCS outpatient 2614 1960.5 MOLINA MCAID MOLINA MCAID 50 2180.08 83.4 999999999 2038.92 2483.3 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 64640_50_1 CDM 360 RC 64640 HCPCS outpatient 2614 1960.5 MOLINA MCR ADV MOLINA MCR ADV 50 2326.46 89 999999999 2038.92 2483.3 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 64640_50_1 CDM 360 RC 64640 HCPCS outpatient 2614 1960.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 2326.46 89 999999999 2038.92 2483.3 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 64640_50_1 CDM 360 RC 64640 HCPCS outpatient 2614 1960.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 2326.46 89 999999999 2038.92 2483.3 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 64640_50_1 CDM 360 RC 64640 HCPCS outpatient 2614 1960.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 2352.6 90 999999999 2038.92 2483.3 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 64640_50_1 CDM 360 RC 64640 HCPCS outpatient 2614 1960.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 2483.3 95 999999999 2038.92 2483.3 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 64640_50_1 CDM 360 RC 64640 HCPCS outpatient 2614 1960.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 2483.3 95 999999999 2038.92 2483.3 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 64640_50_1 CDM 360 RC 64640 HCPCS outpatient 2614 1960.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 2326.46 89 999999999 2038.92 2483.3 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 64640_50_1 CDM 360 RC 64640 HCPCS outpatient 2614 1960.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 2300.32 88 999999999 2038.92 2483.3 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 64640_50_1 CDM 360 RC 64640 HCPCS outpatient 2614 1960.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 2326.46 89 999999999 2038.92 2483.3 percent of total billed charges "UNLISTED PROCEDURE, NERVOUS SYSTEM" 64999_1 CDM 960 RC 64999 HCPCS outpatient 793 594.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50.5 999999999 50.5 832.65 fee schedule "UNLISTED PROCEDURE, NERVOUS SYSTEM" 64999_1 CDM 960 RC 64999 HCPCS outpatient 793 594.75 AETNA MCR ADV AETNA MCR ADV 793 999999999 50.5 832.65 fee schedule "UNLISTED PROCEDURE, NERVOUS SYSTEM" 64999_1 CDM 960 RC 64999 HCPCS outpatient 793 594.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 832.65 999999999 50.5 832.65 fee schedule "UNLISTED PROCEDURE, NERVOUS SYSTEM" 64999_1 CDM 960 RC 64999 HCPCS outpatient 793 594.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 793 999999999 50.5 832.65 fee schedule "UNLISTED PROCEDURE, NERVOUS SYSTEM" 64999_1 CDM 960 RC 64999 HCPCS outpatient 793 594.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 793 999999999 50.5 832.65 fee schedule "UNLISTED PROCEDURE, NERVOUS SYSTEM" 64999_1 CDM 960 RC 64999 HCPCS outpatient 793 594.75 MOLINA MCAID MOLINA MCAID 832.65 999999999 50.5 832.65 fee schedule "UNLISTED PROCEDURE, NERVOUS SYSTEM" 64999_1 CDM 960 RC 64999 HCPCS outpatient 793 594.75 MOLINA MCR ADV MOLINA MCR ADV 793 999999999 50.5 832.65 fee schedule "UNLISTED PROCEDURE, NERVOUS SYSTEM" 64999_1 CDM 960 RC 64999 HCPCS outpatient 793 594.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 793 999999999 50.5 832.65 fee schedule "UNLISTED PROCEDURE, NERVOUS SYSTEM" 64999_1 CDM 960 RC 64999 HCPCS outpatient 793 594.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 793 999999999 50.5 832.65 fee schedule "UNLISTED PROCEDURE, NERVOUS SYSTEM" 64999_1 CDM 960 RC 64999 HCPCS outpatient 793 594.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 999999999 50.5 832.65 "UNLISTED PROCEDURE, NERVOUS SYSTEM" 64999_1 CDM 960 RC 64999 HCPCS outpatient 793 594.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 999999999 50.5 832.65 "UNLISTED PROCEDURE, NERVOUS SYSTEM" 64999_1 CDM 960 RC 64999 HCPCS outpatient 793 594.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 999999999 50.5 832.65 "UNLISTED PROCEDURE, NERVOUS SYSTEM" 64999_1 CDM 960 RC 64999 HCPCS outpatient 793 594.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 793 999999999 50.5 832.65 fee schedule "UNLISTED PROCEDURE, NERVOUS SYSTEM" 64999_1 CDM 960 RC 64999 HCPCS outpatient 793 594.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 999999999 50.5 832.65 "UNLISTED PROCEDURE, NERVOUS SYSTEM" 64999_1 CDM 960 RC 64999 HCPCS outpatient 793 594.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 793 999999999 50.5 832.65 fee schedule "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 65205_1 CDM 360 RC 65205 HCPCS outpatient 87.66 65.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 78.89 999999999 68.37 83.28 case rate "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 65205_1 CDM 360 RC 65205 HCPCS outpatient 87.66 65.75 AETNA MCR ADV AETNA MCR ADV 68.37 78 999999999 68.37 83.28 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 65205_1 CDM 360 RC 65205 HCPCS outpatient 87.66 65.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 76.76 87.57 999999999 68.37 83.28 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 65205_1 CDM 360 RC 65205 HCPCS outpatient 87.66 65.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 74.57 85.07 999999999 68.37 83.28 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 65205_1 CDM 360 RC 65205 HCPCS outpatient 87.66 65.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 74.57 85.07 999999999 68.37 83.28 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 65205_1 CDM 360 RC 65205 HCPCS outpatient 87.66 65.75 MOLINA MCAID MOLINA MCAID 73.11 83.4 999999999 68.37 83.28 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 65205_1 CDM 360 RC 65205 HCPCS outpatient 87.66 65.75 MOLINA MCR ADV MOLINA MCR ADV 78.02 89 999999999 68.37 83.28 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 65205_1 CDM 360 RC 65205 HCPCS outpatient 87.66 65.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 78.02 89 999999999 68.37 83.28 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 65205_1 CDM 360 RC 65205 HCPCS outpatient 87.66 65.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 78.02 89 999999999 68.37 83.28 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 65205_1 CDM 360 RC 65205 HCPCS outpatient 87.66 65.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 78.89 90 999999999 68.37 83.28 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 65205_1 CDM 360 RC 65205 HCPCS outpatient 87.66 65.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 83.28 95 999999999 68.37 83.28 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 65205_1 CDM 360 RC 65205 HCPCS outpatient 87.66 65.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 83.28 95 999999999 68.37 83.28 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 65205_1 CDM 360 RC 65205 HCPCS outpatient 87.66 65.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 78.02 89 999999999 68.37 83.28 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 65205_1 CDM 360 RC 65205 HCPCS outpatient 87.66 65.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 77.14 88 999999999 68.37 83.28 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 65205_1 CDM 360 RC 65205 HCPCS outpatient 87.66 65.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 78.02 89 999999999 68.37 83.28 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 65205_3 CDM 360 RC 65205 HCPCS outpatient 58 43.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 52.2 999999999 45.24 55.1 case rate "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 65205_3 CDM 360 RC 65205 HCPCS outpatient 58 43.5 AETNA MCR ADV AETNA MCR ADV 45.24 78 999999999 45.24 55.1 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 65205_3 CDM 360 RC 65205 HCPCS outpatient 58 43.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50.79 87.57 999999999 45.24 55.1 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 65205_3 CDM 360 RC 65205 HCPCS outpatient 58 43.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 49.34 85.07 999999999 45.24 55.1 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 65205_3 CDM 360 RC 65205 HCPCS outpatient 58 43.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 49.34 85.07 999999999 45.24 55.1 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 65205_3 CDM 360 RC 65205 HCPCS outpatient 58 43.5 MOLINA MCAID MOLINA MCAID 48.37 83.4 999999999 45.24 55.1 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 65205_3 CDM 360 RC 65205 HCPCS outpatient 58 43.5 MOLINA MCR ADV MOLINA MCR ADV 51.62 89 999999999 45.24 55.1 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 65205_3 CDM 360 RC 65205 HCPCS outpatient 58 43.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 51.62 89 999999999 45.24 55.1 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 65205_3 CDM 360 RC 65205 HCPCS outpatient 58 43.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 51.62 89 999999999 45.24 55.1 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 65205_3 CDM 360 RC 65205 HCPCS outpatient 58 43.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 52.2 90 999999999 45.24 55.1 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 65205_3 CDM 360 RC 65205 HCPCS outpatient 58 43.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 55.1 95 999999999 45.24 55.1 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 65205_3 CDM 360 RC 65205 HCPCS outpatient 58 43.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 55.1 95 999999999 45.24 55.1 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 65205_3 CDM 360 RC 65205 HCPCS outpatient 58 43.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 51.62 89 999999999 45.24 55.1 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 65205_3 CDM 360 RC 65205 HCPCS outpatient 58 43.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 51.04 88 999999999 45.24 55.1 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 65205_3 CDM 360 RC 65205 HCPCS outpatient 58 43.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 51.62 89 999999999 45.24 55.1 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 65210_1 CDM 360 RC 65210 HCPCS outpatient 108.54 81.41 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 97.69 999999999 84.66 103.11 case rate "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 65210_1 CDM 360 RC 65210 HCPCS outpatient 108.54 81.41 AETNA MCR ADV AETNA MCR ADV 84.66 78 999999999 84.66 103.11 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 65210_1 CDM 360 RC 65210 HCPCS outpatient 108.54 81.41 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 95.05 87.57 999999999 84.66 103.11 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 65210_1 CDM 360 RC 65210 HCPCS outpatient 108.54 81.41 COORDINATED CARE MCAID COORDINATED CARE MCAID 92.34 85.07 999999999 84.66 103.11 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 65210_1 CDM 360 RC 65210 HCPCS outpatient 108.54 81.41 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 92.34 85.07 999999999 84.66 103.11 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 65210_1 CDM 360 RC 65210 HCPCS outpatient 108.54 81.41 MOLINA MCAID MOLINA MCAID 90.52 83.4 999999999 84.66 103.11 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 65210_1 CDM 360 RC 65210 HCPCS outpatient 108.54 81.41 MOLINA MCR ADV MOLINA MCR ADV 96.6 89 999999999 84.66 103.11 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 65210_1 CDM 360 RC 65210 HCPCS outpatient 108.54 81.41 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 96.6 89 999999999 84.66 103.11 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 65210_1 CDM 360 RC 65210 HCPCS outpatient 108.54 81.41 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 96.6 89 999999999 84.66 103.11 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 65210_1 CDM 360 RC 65210 HCPCS outpatient 108.54 81.41 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 97.69 90 999999999 84.66 103.11 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 65210_1 CDM 360 RC 65210 HCPCS outpatient 108.54 81.41 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 103.11 95 999999999 84.66 103.11 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 65210_1 CDM 360 RC 65210 HCPCS outpatient 108.54 81.41 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 103.11 95 999999999 84.66 103.11 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 65210_1 CDM 360 RC 65210 HCPCS outpatient 108.54 81.41 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 96.6 89 999999999 84.66 103.11 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 65210_1 CDM 360 RC 65210 HCPCS outpatient 108.54 81.41 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 95.52 88 999999999 84.66 103.11 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 65210_1 CDM 360 RC 65210 HCPCS outpatient 108.54 81.41 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 96.6 89 999999999 84.66 103.11 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 65210_3 CDM 360 RC 65210 HCPCS outpatient 80 60 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 72 999999999 62.4 76 case rate "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 65210_3 CDM 360 RC 65210 HCPCS outpatient 80 60 AETNA MCR ADV AETNA MCR ADV 62.4 78 999999999 62.4 76 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 65210_3 CDM 360 RC 65210 HCPCS outpatient 80 60 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 70.06 87.57 999999999 62.4 76 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 65210_3 CDM 360 RC 65210 HCPCS outpatient 80 60 COORDINATED CARE MCAID COORDINATED CARE MCAID 68.06 85.07 999999999 62.4 76 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 65210_3 CDM 360 RC 65210 HCPCS outpatient 80 60 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 68.06 85.07 999999999 62.4 76 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 65210_3 CDM 360 RC 65210 HCPCS outpatient 80 60 MOLINA MCAID MOLINA MCAID 66.72 83.4 999999999 62.4 76 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 65210_3 CDM 360 RC 65210 HCPCS outpatient 80 60 MOLINA MCR ADV MOLINA MCR ADV 71.2 89 999999999 62.4 76 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 65210_3 CDM 360 RC 65210 HCPCS outpatient 80 60 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 71.2 89 999999999 62.4 76 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 65210_3 CDM 360 RC 65210 HCPCS outpatient 80 60 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 71.2 89 999999999 62.4 76 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 65210_3 CDM 360 RC 65210 HCPCS outpatient 80 60 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 72 90 999999999 62.4 76 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 65210_3 CDM 360 RC 65210 HCPCS outpatient 80 60 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 76 95 999999999 62.4 76 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 65210_3 CDM 360 RC 65210 HCPCS outpatient 80 60 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 76 95 999999999 62.4 76 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 65210_3 CDM 360 RC 65210 HCPCS outpatient 80 60 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 71.2 89 999999999 62.4 76 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 65210_3 CDM 360 RC 65210 HCPCS outpatient 80 60 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 70.4 88 999999999 62.4 76 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 65210_3 CDM 360 RC 65210 HCPCS outpatient 80 60 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 71.2 89 999999999 62.4 76 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_1 CDM 360 RC 65220 HCPCS outpatient 122.76 92.07 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 110.48 999999999 95.75 116.62 case rate "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_1 CDM 360 RC 65220 HCPCS outpatient 122.76 92.07 AETNA MCR ADV AETNA MCR ADV 95.75 78 999999999 95.75 116.62 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_1 CDM 360 RC 65220 HCPCS outpatient 122.76 92.07 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 107.5 87.57 999999999 95.75 116.62 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_1 CDM 360 RC 65220 HCPCS outpatient 122.76 92.07 COORDINATED CARE MCAID COORDINATED CARE MCAID 104.43 85.07 999999999 95.75 116.62 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_1 CDM 360 RC 65220 HCPCS outpatient 122.76 92.07 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 104.43 85.07 999999999 95.75 116.62 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_1 CDM 360 RC 65220 HCPCS outpatient 122.76 92.07 MOLINA MCAID MOLINA MCAID 102.38 83.4 999999999 95.75 116.62 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_1 CDM 360 RC 65220 HCPCS outpatient 122.76 92.07 MOLINA MCR ADV MOLINA MCR ADV 109.26 89 999999999 95.75 116.62 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_1 CDM 360 RC 65220 HCPCS outpatient 122.76 92.07 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 109.26 89 999999999 95.75 116.62 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_1 CDM 360 RC 65220 HCPCS outpatient 122.76 92.07 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 109.26 89 999999999 95.75 116.62 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_1 CDM 360 RC 65220 HCPCS outpatient 122.76 92.07 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 110.48 90 999999999 95.75 116.62 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_1 CDM 360 RC 65220 HCPCS outpatient 122.76 92.07 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 116.62 95 999999999 95.75 116.62 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_1 CDM 360 RC 65220 HCPCS outpatient 122.76 92.07 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 116.62 95 999999999 95.75 116.62 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_1 CDM 360 RC 65220 HCPCS outpatient 122.76 92.07 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 109.26 89 999999999 95.75 116.62 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_1 CDM 360 RC 65220 HCPCS outpatient 122.76 92.07 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 108.03 88 999999999 95.75 116.62 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_1 CDM 360 RC 65220 HCPCS outpatient 122.76 92.07 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 109.26 89 999999999 95.75 116.62 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_2 CDM 360 RC 65220 HCPCS outpatient 122.76 92.07 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 110.48 999999999 95.75 116.62 case rate "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_2 CDM 360 RC 65220 HCPCS outpatient 122.76 92.07 AETNA MCR ADV AETNA MCR ADV 95.75 78 999999999 95.75 116.62 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_2 CDM 360 RC 65220 HCPCS outpatient 122.76 92.07 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 107.5 87.57 999999999 95.75 116.62 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_2 CDM 360 RC 65220 HCPCS outpatient 122.76 92.07 COORDINATED CARE MCAID COORDINATED CARE MCAID 104.43 85.07 999999999 95.75 116.62 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_2 CDM 360 RC 65220 HCPCS outpatient 122.76 92.07 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 104.43 85.07 999999999 95.75 116.62 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_2 CDM 360 RC 65220 HCPCS outpatient 122.76 92.07 MOLINA MCAID MOLINA MCAID 102.38 83.4 999999999 95.75 116.62 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_2 CDM 360 RC 65220 HCPCS outpatient 122.76 92.07 MOLINA MCR ADV MOLINA MCR ADV 109.26 89 999999999 95.75 116.62 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_2 CDM 360 RC 65220 HCPCS outpatient 122.76 92.07 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 109.26 89 999999999 95.75 116.62 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_2 CDM 360 RC 65220 HCPCS outpatient 122.76 92.07 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 109.26 89 999999999 95.75 116.62 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_2 CDM 360 RC 65220 HCPCS outpatient 122.76 92.07 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 110.48 90 999999999 95.75 116.62 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_2 CDM 360 RC 65220 HCPCS outpatient 122.76 92.07 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 116.62 95 999999999 95.75 116.62 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_2 CDM 360 RC 65220 HCPCS outpatient 122.76 92.07 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 116.62 95 999999999 95.75 116.62 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_2 CDM 360 RC 65220 HCPCS outpatient 122.76 92.07 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 109.26 89 999999999 95.75 116.62 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_2 CDM 360 RC 65220 HCPCS outpatient 122.76 92.07 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 108.03 88 999999999 95.75 116.62 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_2 CDM 360 RC 65220 HCPCS outpatient 122.76 92.07 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 109.26 89 999999999 95.75 116.62 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_3 CDM 360 RC 65220 HCPCS outpatient 120 90 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 108 999999999 93.6 114 case rate "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_3 CDM 360 RC 65220 HCPCS outpatient 120 90 AETNA MCR ADV AETNA MCR ADV 93.6 78 999999999 93.6 114 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_3 CDM 360 RC 65220 HCPCS outpatient 120 90 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 105.08 87.57 999999999 93.6 114 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_3 CDM 360 RC 65220 HCPCS outpatient 120 90 COORDINATED CARE MCAID COORDINATED CARE MCAID 102.08 85.07 999999999 93.6 114 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_3 CDM 360 RC 65220 HCPCS outpatient 120 90 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 102.08 85.07 999999999 93.6 114 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_3 CDM 360 RC 65220 HCPCS outpatient 120 90 MOLINA MCAID MOLINA MCAID 100.08 83.4 999999999 93.6 114 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_3 CDM 360 RC 65220 HCPCS outpatient 120 90 MOLINA MCR ADV MOLINA MCR ADV 106.8 89 999999999 93.6 114 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_3 CDM 360 RC 65220 HCPCS outpatient 120 90 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 106.8 89 999999999 93.6 114 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_3 CDM 360 RC 65220 HCPCS outpatient 120 90 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 106.8 89 999999999 93.6 114 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_3 CDM 360 RC 65220 HCPCS outpatient 120 90 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 108 90 999999999 93.6 114 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_3 CDM 360 RC 65220 HCPCS outpatient 120 90 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 114 95 999999999 93.6 114 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_3 CDM 360 RC 65220 HCPCS outpatient 120 90 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 114 95 999999999 93.6 114 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_3 CDM 360 RC 65220 HCPCS outpatient 120 90 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 106.8 89 999999999 93.6 114 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_3 CDM 360 RC 65220 HCPCS outpatient 120 90 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 105.6 88 999999999 93.6 114 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 65220_3 CDM 360 RC 65220 HCPCS outpatient 120 90 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 106.8 89 999999999 93.6 114 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITH SLIT LAMP" 65222_3 CDM 360 RC 65222 HCPCS outpatient 140 105 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 126 999999999 109.2 133 case rate "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITH SLIT LAMP" 65222_3 CDM 360 RC 65222 HCPCS outpatient 140 105 AETNA MCR ADV AETNA MCR ADV 109.2 78 999999999 109.2 133 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITH SLIT LAMP" 65222_3 CDM 360 RC 65222 HCPCS outpatient 140 105 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 122.6 87.57 999999999 109.2 133 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITH SLIT LAMP" 65222_3 CDM 360 RC 65222 HCPCS outpatient 140 105 COORDINATED CARE MCAID COORDINATED CARE MCAID 119.1 85.07 999999999 109.2 133 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITH SLIT LAMP" 65222_3 CDM 360 RC 65222 HCPCS outpatient 140 105 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 119.1 85.07 999999999 109.2 133 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITH SLIT LAMP" 65222_3 CDM 360 RC 65222 HCPCS outpatient 140 105 MOLINA MCAID MOLINA MCAID 116.76 83.4 999999999 109.2 133 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITH SLIT LAMP" 65222_3 CDM 360 RC 65222 HCPCS outpatient 140 105 MOLINA MCR ADV MOLINA MCR ADV 124.6 89 999999999 109.2 133 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITH SLIT LAMP" 65222_3 CDM 360 RC 65222 HCPCS outpatient 140 105 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 124.6 89 999999999 109.2 133 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITH SLIT LAMP" 65222_3 CDM 360 RC 65222 HCPCS outpatient 140 105 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 124.6 89 999999999 109.2 133 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITH SLIT LAMP" 65222_3 CDM 360 RC 65222 HCPCS outpatient 140 105 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 126 90 999999999 109.2 133 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITH SLIT LAMP" 65222_3 CDM 360 RC 65222 HCPCS outpatient 140 105 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 133 95 999999999 109.2 133 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITH SLIT LAMP" 65222_3 CDM 360 RC 65222 HCPCS outpatient 140 105 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 133 95 999999999 109.2 133 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITH SLIT LAMP" 65222_3 CDM 360 RC 65222 HCPCS outpatient 140 105 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 124.6 89 999999999 109.2 133 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITH SLIT LAMP" 65222_3 CDM 360 RC 65222 HCPCS outpatient 140 105 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 123.2 88 999999999 109.2 133 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITH SLIT LAMP" 65222_3 CDM 360 RC 65222 HCPCS outpatient 140 105 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 124.6 89 999999999 109.2 133 percent of total billed charges "REMOVAL OF EMBEDDED FOREIGN BODY, EYELID" 67938_3 CDM 360 RC 67938 HCPCS outpatient 572 429 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 514.8 999999999 446.16 543.4 case rate "REMOVAL OF EMBEDDED FOREIGN BODY, EYELID" 67938_3 CDM 360 RC 67938 HCPCS outpatient 572 429 AETNA MCR ADV AETNA MCR ADV 446.16 78 999999999 446.16 543.4 percent of total billed charges "REMOVAL OF EMBEDDED FOREIGN BODY, EYELID" 67938_3 CDM 360 RC 67938 HCPCS outpatient 572 429 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 500.9 87.57 999999999 446.16 543.4 percent of total billed charges "REMOVAL OF EMBEDDED FOREIGN BODY, EYELID" 67938_3 CDM 360 RC 67938 HCPCS outpatient 572 429 COORDINATED CARE MCAID COORDINATED CARE MCAID 486.6 85.07 999999999 446.16 543.4 percent of total billed charges "REMOVAL OF EMBEDDED FOREIGN BODY, EYELID" 67938_3 CDM 360 RC 67938 HCPCS outpatient 572 429 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 486.6 85.07 999999999 446.16 543.4 percent of total billed charges "REMOVAL OF EMBEDDED FOREIGN BODY, EYELID" 67938_3 CDM 360 RC 67938 HCPCS outpatient 572 429 MOLINA MCAID MOLINA MCAID 477.05 83.4 999999999 446.16 543.4 percent of total billed charges "REMOVAL OF EMBEDDED FOREIGN BODY, EYELID" 67938_3 CDM 360 RC 67938 HCPCS outpatient 572 429 MOLINA MCR ADV MOLINA MCR ADV 509.08 89 999999999 446.16 543.4 percent of total billed charges "REMOVAL OF EMBEDDED FOREIGN BODY, EYELID" 67938_3 CDM 360 RC 67938 HCPCS outpatient 572 429 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 509.08 89 999999999 446.16 543.4 percent of total billed charges "REMOVAL OF EMBEDDED FOREIGN BODY, EYELID" 67938_3 CDM 360 RC 67938 HCPCS outpatient 572 429 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 509.08 89 999999999 446.16 543.4 percent of total billed charges "REMOVAL OF EMBEDDED FOREIGN BODY, EYELID" 67938_3 CDM 360 RC 67938 HCPCS outpatient 572 429 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 514.8 90 999999999 446.16 543.4 percent of total billed charges "REMOVAL OF EMBEDDED FOREIGN BODY, EYELID" 67938_3 CDM 360 RC 67938 HCPCS outpatient 572 429 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 543.4 95 999999999 446.16 543.4 percent of total billed charges "REMOVAL OF EMBEDDED FOREIGN BODY, EYELID" 67938_3 CDM 360 RC 67938 HCPCS outpatient 572 429 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 543.4 95 999999999 446.16 543.4 percent of total billed charges "REMOVAL OF EMBEDDED FOREIGN BODY, EYELID" 67938_3 CDM 360 RC 67938 HCPCS outpatient 572 429 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 509.08 89 999999999 446.16 543.4 percent of total billed charges "REMOVAL OF EMBEDDED FOREIGN BODY, EYELID" 67938_3 CDM 360 RC 67938 HCPCS outpatient 572 429 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 503.36 88 999999999 446.16 543.4 percent of total billed charges "REMOVAL OF EMBEDDED FOREIGN BODY, EYELID" 67938_3 CDM 360 RC 67938 HCPCS outpatient 572 429 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 509.08 89 999999999 446.16 543.4 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_1 CDM 360 RC 69200 HCPCS outpatient 142.14 106.61 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 127.93 999999999 110.87 135.03 case rate REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_1 CDM 360 RC 69200 HCPCS outpatient 142.14 106.61 AETNA MCR ADV AETNA MCR ADV 110.87 78 999999999 110.87 135.03 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_1 CDM 360 RC 69200 HCPCS outpatient 142.14 106.61 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 124.47 87.57 999999999 110.87 135.03 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_1 CDM 360 RC 69200 HCPCS outpatient 142.14 106.61 COORDINATED CARE MCAID COORDINATED CARE MCAID 120.92 85.07 999999999 110.87 135.03 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_1 CDM 360 RC 69200 HCPCS outpatient 142.14 106.61 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 120.92 85.07 999999999 110.87 135.03 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_1 CDM 360 RC 69200 HCPCS outpatient 142.14 106.61 MOLINA MCAID MOLINA MCAID 118.54 83.4 999999999 110.87 135.03 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_1 CDM 360 RC 69200 HCPCS outpatient 142.14 106.61 MOLINA MCR ADV MOLINA MCR ADV 126.5 89 999999999 110.87 135.03 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_1 CDM 360 RC 69200 HCPCS outpatient 142.14 106.61 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 126.5 89 999999999 110.87 135.03 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_1 CDM 360 RC 69200 HCPCS outpatient 142.14 106.61 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 126.5 89 999999999 110.87 135.03 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_1 CDM 360 RC 69200 HCPCS outpatient 142.14 106.61 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 127.93 90 999999999 110.87 135.03 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_1 CDM 360 RC 69200 HCPCS outpatient 142.14 106.61 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 135.03 95 999999999 110.87 135.03 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_1 CDM 360 RC 69200 HCPCS outpatient 142.14 106.61 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 135.03 95 999999999 110.87 135.03 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_1 CDM 360 RC 69200 HCPCS outpatient 142.14 106.61 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 126.5 89 999999999 110.87 135.03 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_1 CDM 360 RC 69200 HCPCS outpatient 142.14 106.61 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 125.08 88 999999999 110.87 135.03 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_1 CDM 360 RC 69200 HCPCS outpatient 142.14 106.61 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 126.5 89 999999999 110.87 135.03 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_2 CDM 360 RC 69200 HCPCS outpatient 142.14 106.61 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 127.93 999999999 110.87 135.03 case rate REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_2 CDM 360 RC 69200 HCPCS outpatient 142.14 106.61 AETNA MCR ADV AETNA MCR ADV 110.87 78 999999999 110.87 135.03 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_2 CDM 360 RC 69200 HCPCS outpatient 142.14 106.61 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 124.47 87.57 999999999 110.87 135.03 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_2 CDM 360 RC 69200 HCPCS outpatient 142.14 106.61 COORDINATED CARE MCAID COORDINATED CARE MCAID 120.92 85.07 999999999 110.87 135.03 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_2 CDM 360 RC 69200 HCPCS outpatient 142.14 106.61 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 120.92 85.07 999999999 110.87 135.03 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_2 CDM 360 RC 69200 HCPCS outpatient 142.14 106.61 MOLINA MCAID MOLINA MCAID 118.54 83.4 999999999 110.87 135.03 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_2 CDM 360 RC 69200 HCPCS outpatient 142.14 106.61 MOLINA MCR ADV MOLINA MCR ADV 126.5 89 999999999 110.87 135.03 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_2 CDM 360 RC 69200 HCPCS outpatient 142.14 106.61 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 126.5 89 999999999 110.87 135.03 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_2 CDM 360 RC 69200 HCPCS outpatient 142.14 106.61 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 126.5 89 999999999 110.87 135.03 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_2 CDM 360 RC 69200 HCPCS outpatient 142.14 106.61 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 127.93 90 999999999 110.87 135.03 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_2 CDM 360 RC 69200 HCPCS outpatient 142.14 106.61 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 135.03 95 999999999 110.87 135.03 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_2 CDM 360 RC 69200 HCPCS outpatient 142.14 106.61 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 135.03 95 999999999 110.87 135.03 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_2 CDM 360 RC 69200 HCPCS outpatient 142.14 106.61 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 126.5 89 999999999 110.87 135.03 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_2 CDM 360 RC 69200 HCPCS outpatient 142.14 106.61 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 125.08 88 999999999 110.87 135.03 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_2 CDM 360 RC 69200 HCPCS outpatient 142.14 106.61 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 126.5 89 999999999 110.87 135.03 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_3 CDM 360 RC 69200 HCPCS outpatient 164 123 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 147.6 999999999 127.92 155.8 case rate REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_3 CDM 360 RC 69200 HCPCS outpatient 164 123 AETNA MCR ADV AETNA MCR ADV 127.92 78 999999999 127.92 155.8 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_3 CDM 360 RC 69200 HCPCS outpatient 164 123 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 143.61 87.57 999999999 127.92 155.8 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_3 CDM 360 RC 69200 HCPCS outpatient 164 123 COORDINATED CARE MCAID COORDINATED CARE MCAID 139.51 85.07 999999999 127.92 155.8 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_3 CDM 360 RC 69200 HCPCS outpatient 164 123 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 139.51 85.07 999999999 127.92 155.8 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_3 CDM 360 RC 69200 HCPCS outpatient 164 123 MOLINA MCAID MOLINA MCAID 136.78 83.4 999999999 127.92 155.8 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_3 CDM 360 RC 69200 HCPCS outpatient 164 123 MOLINA MCR ADV MOLINA MCR ADV 145.96 89 999999999 127.92 155.8 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_3 CDM 360 RC 69200 HCPCS outpatient 164 123 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 145.96 89 999999999 127.92 155.8 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_3 CDM 360 RC 69200 HCPCS outpatient 164 123 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 145.96 89 999999999 127.92 155.8 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_3 CDM 360 RC 69200 HCPCS outpatient 164 123 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 147.6 90 999999999 127.92 155.8 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_3 CDM 360 RC 69200 HCPCS outpatient 164 123 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 155.8 95 999999999 127.92 155.8 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_3 CDM 360 RC 69200 HCPCS outpatient 164 123 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 155.8 95 999999999 127.92 155.8 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_3 CDM 360 RC 69200 HCPCS outpatient 164 123 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 145.96 89 999999999 127.92 155.8 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_3 CDM 360 RC 69200 HCPCS outpatient 164 123 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 144.32 88 999999999 127.92 155.8 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 69200_3 CDM 360 RC 69200 HCPCS outpatient 164 123 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 145.96 89 999999999 127.92 155.8 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA 69205_1 CDM 360 RC 69205 HCPCS outpatient 288.24 216.18 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 259.42 999999999 224.83 273.83 case rate REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA 69205_1 CDM 360 RC 69205 HCPCS outpatient 288.24 216.18 AETNA MCR ADV AETNA MCR ADV 224.83 78 999999999 224.83 273.83 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA 69205_1 CDM 360 RC 69205 HCPCS outpatient 288.24 216.18 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 252.41 87.57 999999999 224.83 273.83 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA 69205_1 CDM 360 RC 69205 HCPCS outpatient 288.24 216.18 COORDINATED CARE MCAID COORDINATED CARE MCAID 245.21 85.07 999999999 224.83 273.83 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA 69205_1 CDM 360 RC 69205 HCPCS outpatient 288.24 216.18 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 245.21 85.07 999999999 224.83 273.83 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA 69205_1 CDM 360 RC 69205 HCPCS outpatient 288.24 216.18 MOLINA MCAID MOLINA MCAID 240.39 83.4 999999999 224.83 273.83 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA 69205_1 CDM 360 RC 69205 HCPCS outpatient 288.24 216.18 MOLINA MCR ADV MOLINA MCR ADV 256.53 89 999999999 224.83 273.83 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA 69205_1 CDM 360 RC 69205 HCPCS outpatient 288.24 216.18 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 256.53 89 999999999 224.83 273.83 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA 69205_1 CDM 360 RC 69205 HCPCS outpatient 288.24 216.18 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 256.53 89 999999999 224.83 273.83 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA 69205_1 CDM 360 RC 69205 HCPCS outpatient 288.24 216.18 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 259.42 90 999999999 224.83 273.83 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA 69205_1 CDM 360 RC 69205 HCPCS outpatient 288.24 216.18 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 273.83 95 999999999 224.83 273.83 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA 69205_1 CDM 360 RC 69205 HCPCS outpatient 288.24 216.18 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 273.83 95 999999999 224.83 273.83 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA 69205_1 CDM 360 RC 69205 HCPCS outpatient 288.24 216.18 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 256.53 89 999999999 224.83 273.83 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA 69205_1 CDM 360 RC 69205 HCPCS outpatient 288.24 216.18 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 253.65 88 999999999 224.83 273.83 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA 69205_1 CDM 360 RC 69205 HCPCS outpatient 288.24 216.18 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 256.53 89 999999999 224.83 273.83 percent of total billed charges "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_1 CDM 960 RC 69209 HCPCS outpatient 47.1 35.33 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 21.46 999999999 9.51 47.1 fee schedule "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_1 CDM 960 RC 69209 HCPCS outpatient 47.1 35.33 AETNA MCR ADV AETNA MCR ADV 47.1 999999999 9.51 47.1 fee schedule "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_1 CDM 960 RC 69209 HCPCS outpatient 47.1 35.33 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 9.99 999999999 9.51 47.1 fee schedule "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_1 CDM 960 RC 69209 HCPCS outpatient 47.1 35.33 COORDINATED CARE MCAID COORDINATED CARE MCAID 9.51 999999999 9.51 47.1 fee schedule "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_1 CDM 960 RC 69209 HCPCS outpatient 47.1 35.33 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 47.1 999999999 9.51 47.1 fee schedule "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_1 CDM 960 RC 69209 HCPCS outpatient 47.1 35.33 MOLINA MCAID MOLINA MCAID 9.99 999999999 9.51 47.1 fee schedule "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_1 CDM 960 RC 69209 HCPCS outpatient 47.1 35.33 MOLINA MCR ADV MOLINA MCR ADV 47.1 999999999 9.51 47.1 fee schedule "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_1 CDM 960 RC 69209 HCPCS outpatient 47.1 35.33 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 47.1 999999999 9.51 47.1 fee schedule "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_1 CDM 960 RC 69209 HCPCS outpatient 47.1 35.33 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 47.1 999999999 9.51 47.1 fee schedule "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_1 CDM 960 RC 69209 HCPCS outpatient 47.1 35.33 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 17.28 999999999 9.51 47.1 fee schedule "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_1 CDM 960 RC 69209 HCPCS outpatient 47.1 35.33 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 20 999999999 9.51 47.1 fee schedule "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_1 CDM 960 RC 69209 HCPCS outpatient 47.1 35.33 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 20 999999999 9.51 47.1 fee schedule "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_1 CDM 960 RC 69209 HCPCS outpatient 47.1 35.33 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 47.1 999999999 9.51 47.1 fee schedule "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_1 CDM 960 RC 69209 HCPCS outpatient 47.1 35.33 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 21.94 999999999 9.51 47.1 fee schedule "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_1 CDM 960 RC 69209 HCPCS outpatient 47.1 35.33 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 47.1 999999999 9.51 47.1 fee schedule "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_2 CDM 960 RC 69209 HCPCS outpatient 47.1 35.33 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 21.46 999999999 9.51 47.1 fee schedule "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_2 CDM 960 RC 69209 HCPCS outpatient 47.1 35.33 AETNA MCR ADV AETNA MCR ADV 47.1 999999999 9.51 47.1 fee schedule "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_2 CDM 960 RC 69209 HCPCS outpatient 47.1 35.33 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 9.99 999999999 9.51 47.1 fee schedule "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_2 CDM 960 RC 69209 HCPCS outpatient 47.1 35.33 COORDINATED CARE MCAID COORDINATED CARE MCAID 9.51 999999999 9.51 47.1 fee schedule "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_2 CDM 960 RC 69209 HCPCS outpatient 47.1 35.33 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 47.1 999999999 9.51 47.1 fee schedule "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_2 CDM 960 RC 69209 HCPCS outpatient 47.1 35.33 MOLINA MCAID MOLINA MCAID 9.99 999999999 9.51 47.1 fee schedule "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_2 CDM 960 RC 69209 HCPCS outpatient 47.1 35.33 MOLINA MCR ADV MOLINA MCR ADV 47.1 999999999 9.51 47.1 fee schedule "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_2 CDM 960 RC 69209 HCPCS outpatient 47.1 35.33 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 47.1 999999999 9.51 47.1 fee schedule "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_2 CDM 960 RC 69209 HCPCS outpatient 47.1 35.33 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 47.1 999999999 9.51 47.1 fee schedule "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_2 CDM 960 RC 69209 HCPCS outpatient 47.1 35.33 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 17.28 999999999 9.51 47.1 fee schedule "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_2 CDM 960 RC 69209 HCPCS outpatient 47.1 35.33 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 20 999999999 9.51 47.1 fee schedule "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_2 CDM 960 RC 69209 HCPCS outpatient 47.1 35.33 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 20 999999999 9.51 47.1 fee schedule "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_2 CDM 960 RC 69209 HCPCS outpatient 47.1 35.33 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 47.1 999999999 9.51 47.1 fee schedule "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_2 CDM 960 RC 69209 HCPCS outpatient 47.1 35.33 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 21.94 999999999 9.51 47.1 fee schedule "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_2 CDM 960 RC 69209 HCPCS outpatient 47.1 35.33 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 47.1 999999999 9.51 47.1 fee schedule "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_3 CDM 960 RC 69209 HCPCS outpatient 31 23.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 21.46 999999999 9.51 31 fee schedule "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_3 CDM 960 RC 69209 HCPCS outpatient 31 23.25 AETNA MCR ADV AETNA MCR ADV 31 999999999 9.51 31 fee schedule "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_3 CDM 960 RC 69209 HCPCS outpatient 31 23.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 9.99 999999999 9.51 31 fee schedule "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_3 CDM 960 RC 69209 HCPCS outpatient 31 23.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 9.51 999999999 9.51 31 fee schedule "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_3 CDM 960 RC 69209 HCPCS outpatient 31 23.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 31 999999999 9.51 31 fee schedule "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_3 CDM 960 RC 69209 HCPCS outpatient 31 23.25 MOLINA MCAID MOLINA MCAID 9.99 999999999 9.51 31 fee schedule "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_3 CDM 960 RC 69209 HCPCS outpatient 31 23.25 MOLINA MCR ADV MOLINA MCR ADV 31 999999999 9.51 31 fee schedule "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_3 CDM 960 RC 69209 HCPCS outpatient 31 23.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 31 999999999 9.51 31 fee schedule "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_3 CDM 960 RC 69209 HCPCS outpatient 31 23.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 31 999999999 9.51 31 fee schedule "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_3 CDM 960 RC 69209 HCPCS outpatient 31 23.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 17.28 999999999 9.51 31 fee schedule "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_3 CDM 960 RC 69209 HCPCS outpatient 31 23.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 20 999999999 9.51 31 fee schedule "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_3 CDM 960 RC 69209 HCPCS outpatient 31 23.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 20 999999999 9.51 31 fee schedule "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_3 CDM 960 RC 69209 HCPCS outpatient 31 23.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 31 999999999 9.51 31 fee schedule "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_3 CDM 960 RC 69209 HCPCS outpatient 31 23.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 21.94 999999999 9.51 31 fee schedule "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 69209_3 CDM 960 RC 69209 HCPCS outpatient 31 23.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 31 999999999 9.51 31 fee schedule "REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION, UNILATERAL" 69210_3 CDM 360 RC 69210 HCPCS outpatient 96 72 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 86.4 999999999 74.88 91.2 case rate "REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION, UNILATERAL" 69210_3 CDM 360 RC 69210 HCPCS outpatient 96 72 AETNA MCR ADV AETNA MCR ADV 74.88 78 999999999 74.88 91.2 percent of total billed charges "REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION, UNILATERAL" 69210_3 CDM 360 RC 69210 HCPCS outpatient 96 72 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 84.07 87.57 999999999 74.88 91.2 percent of total billed charges "REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION, UNILATERAL" 69210_3 CDM 360 RC 69210 HCPCS outpatient 96 72 COORDINATED CARE MCAID COORDINATED CARE MCAID 81.67 85.07 999999999 74.88 91.2 percent of total billed charges "REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION, UNILATERAL" 69210_3 CDM 360 RC 69210 HCPCS outpatient 96 72 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 81.67 85.07 999999999 74.88 91.2 percent of total billed charges "REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION, UNILATERAL" 69210_3 CDM 360 RC 69210 HCPCS outpatient 96 72 MOLINA MCAID MOLINA MCAID 80.06 83.4 999999999 74.88 91.2 percent of total billed charges "REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION, UNILATERAL" 69210_3 CDM 360 RC 69210 HCPCS outpatient 96 72 MOLINA MCR ADV MOLINA MCR ADV 85.44 89 999999999 74.88 91.2 percent of total billed charges "REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION, UNILATERAL" 69210_3 CDM 360 RC 69210 HCPCS outpatient 96 72 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 85.44 89 999999999 74.88 91.2 percent of total billed charges "REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION, UNILATERAL" 69210_3 CDM 360 RC 69210 HCPCS outpatient 96 72 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 85.44 89 999999999 74.88 91.2 percent of total billed charges "REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION, UNILATERAL" 69210_3 CDM 360 RC 69210 HCPCS outpatient 96 72 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 86.4 90 999999999 74.88 91.2 percent of total billed charges "REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION, UNILATERAL" 69210_3 CDM 360 RC 69210 HCPCS outpatient 96 72 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 91.2 95 999999999 74.88 91.2 percent of total billed charges "REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION, UNILATERAL" 69210_3 CDM 360 RC 69210 HCPCS outpatient 96 72 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 91.2 95 999999999 74.88 91.2 percent of total billed charges "REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION, UNILATERAL" 69210_3 CDM 360 RC 69210 HCPCS outpatient 96 72 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 85.44 89 999999999 74.88 91.2 percent of total billed charges "REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION, UNILATERAL" 69210_3 CDM 360 RC 69210 HCPCS outpatient 96 72 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 84.48 88 999999999 74.88 91.2 percent of total billed charges "REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION, UNILATERAL" 69210_3 CDM 360 RC 69210 HCPCS outpatient 96 72 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 85.44 89 999999999 74.88 91.2 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; WITH INTERPRETATION AND REPORT" 7309300001_1 CDM 730 RC 93000 HCPCS outpatient 340 255 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 306 90 999999999 265.2 323 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; WITH INTERPRETATION AND REPORT" 7309300001_1 CDM 730 RC 93000 HCPCS outpatient 340 255 AETNA MCR ADV AETNA MCR ADV 265.2 78 999999999 265.2 323 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; WITH INTERPRETATION AND REPORT" 7309300001_1 CDM 730 RC 93000 HCPCS outpatient 340 255 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 297.74 87.57 999999999 265.2 323 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; WITH INTERPRETATION AND REPORT" 7309300001_1 CDM 730 RC 93000 HCPCS outpatient 340 255 COORDINATED CARE MCAID COORDINATED CARE MCAID 289.24 85.07 999999999 265.2 323 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; WITH INTERPRETATION AND REPORT" 7309300001_1 CDM 730 RC 93000 HCPCS outpatient 340 255 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 289.24 85.07 999999999 265.2 323 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; WITH INTERPRETATION AND REPORT" 7309300001_1 CDM 730 RC 93000 HCPCS outpatient 340 255 MOLINA MCAID MOLINA MCAID 283.56 83.4 999999999 265.2 323 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; WITH INTERPRETATION AND REPORT" 7309300001_1 CDM 730 RC 93000 HCPCS outpatient 340 255 MOLINA MCR ADV MOLINA MCR ADV 302.6 89 999999999 265.2 323 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; WITH INTERPRETATION AND REPORT" 7309300001_1 CDM 730 RC 93000 HCPCS outpatient 340 255 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 302.6 89 999999999 265.2 323 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; WITH INTERPRETATION AND REPORT" 7309300001_1 CDM 730 RC 93000 HCPCS outpatient 340 255 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 302.6 89 999999999 265.2 323 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; WITH INTERPRETATION AND REPORT" 7309300001_1 CDM 730 RC 93000 HCPCS outpatient 340 255 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 306 90 999999999 265.2 323 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; WITH INTERPRETATION AND REPORT" 7309300001_1 CDM 730 RC 93000 HCPCS outpatient 340 255 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 323 95 999999999 265.2 323 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; WITH INTERPRETATION AND REPORT" 7309300001_1 CDM 730 RC 93000 HCPCS outpatient 340 255 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 323 95 999999999 265.2 323 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; WITH INTERPRETATION AND REPORT" 7309300001_1 CDM 730 RC 93000 HCPCS outpatient 340 255 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 302.6 89 999999999 265.2 323 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; WITH INTERPRETATION AND REPORT" 7309300001_1 CDM 730 RC 93000 HCPCS outpatient 340 255 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 299.2 88 999999999 265.2 323 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; WITH INTERPRETATION AND REPORT" 7309300001_1 CDM 730 RC 93000 HCPCS outpatient 340 255 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 302.6 89 999999999 265.2 323 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT, PERFORMED AS A SCREENING FOR THE INITIAL PREVENTIVE PHYSICAL EXAMINATION" 730G040401_1 CDM 730 RC G0404 HCPCS outpatient 139 104.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 125.1 90 999999999 108.42 132.05 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT, PERFORMED AS A SCREENING FOR THE INITIAL PREVENTIVE PHYSICAL EXAMINATION" 730G040401_1 CDM 730 RC G0404 HCPCS outpatient 139 104.25 AETNA MCR ADV AETNA MCR ADV 108.42 78 999999999 108.42 132.05 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT, PERFORMED AS A SCREENING FOR THE INITIAL PREVENTIVE PHYSICAL EXAMINATION" 730G040401_1 CDM 730 RC G0404 HCPCS outpatient 139 104.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 121.72 87.57 999999999 108.42 132.05 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT, PERFORMED AS A SCREENING FOR THE INITIAL PREVENTIVE PHYSICAL EXAMINATION" 730G040401_1 CDM 730 RC G0404 HCPCS outpatient 139 104.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 118.25 85.07 999999999 108.42 132.05 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT, PERFORMED AS A SCREENING FOR THE INITIAL PREVENTIVE PHYSICAL EXAMINATION" 730G040401_1 CDM 730 RC G0404 HCPCS outpatient 139 104.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 118.25 85.07 999999999 108.42 132.05 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT, PERFORMED AS A SCREENING FOR THE INITIAL PREVENTIVE PHYSICAL EXAMINATION" 730G040401_1 CDM 730 RC G0404 HCPCS outpatient 139 104.25 MOLINA MCAID MOLINA MCAID 115.93 83.4 999999999 108.42 132.05 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT, PERFORMED AS A SCREENING FOR THE INITIAL PREVENTIVE PHYSICAL EXAMINATION" 730G040401_1 CDM 730 RC G0404 HCPCS outpatient 139 104.25 MOLINA MCR ADV MOLINA MCR ADV 123.71 89 999999999 108.42 132.05 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT, PERFORMED AS A SCREENING FOR THE INITIAL PREVENTIVE PHYSICAL EXAMINATION" 730G040401_1 CDM 730 RC G0404 HCPCS outpatient 139 104.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 123.71 89 999999999 108.42 132.05 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT, PERFORMED AS A SCREENING FOR THE INITIAL PREVENTIVE PHYSICAL EXAMINATION" 730G040401_1 CDM 730 RC G0404 HCPCS outpatient 139 104.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 123.71 89 999999999 108.42 132.05 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT, PERFORMED AS A SCREENING FOR THE INITIAL PREVENTIVE PHYSICAL EXAMINATION" 730G040401_1 CDM 730 RC G0404 HCPCS outpatient 139 104.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 125.1 90 999999999 108.42 132.05 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT, PERFORMED AS A SCREENING FOR THE INITIAL PREVENTIVE PHYSICAL EXAMINATION" 730G040401_1 CDM 730 RC G0404 HCPCS outpatient 139 104.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 132.05 95 999999999 108.42 132.05 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT, PERFORMED AS A SCREENING FOR THE INITIAL PREVENTIVE PHYSICAL EXAMINATION" 730G040401_1 CDM 730 RC G0404 HCPCS outpatient 139 104.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 132.05 95 999999999 108.42 132.05 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT, PERFORMED AS A SCREENING FOR THE INITIAL PREVENTIVE PHYSICAL EXAMINATION" 730G040401_1 CDM 730 RC G0404 HCPCS outpatient 139 104.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 123.71 89 999999999 108.42 132.05 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT, PERFORMED AS A SCREENING FOR THE INITIAL PREVENTIVE PHYSICAL EXAMINATION" 730G040401_1 CDM 730 RC G0404 HCPCS outpatient 139 104.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 122.32 88 999999999 108.42 132.05 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT, PERFORMED AS A SCREENING FOR THE INITIAL PREVENTIVE PHYSICAL EXAMINATION" 730G040401_1 CDM 730 RC G0404 HCPCS outpatient 139 104.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 123.71 89 999999999 108.42 132.05 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 7611202101_1 CDM 761 RC 12021 HCPCS outpatient 425 318.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 382.5 999999999 331.5 403.75 case rate TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 7611202101_1 CDM 761 RC 12021 HCPCS outpatient 425 318.75 AETNA MCR ADV AETNA MCR ADV 331.5 78 999999999 331.5 403.75 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 7611202101_1 CDM 761 RC 12021 HCPCS outpatient 425 318.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 372.17 87.57 999999999 331.5 403.75 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 7611202101_1 CDM 761 RC 12021 HCPCS outpatient 425 318.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 361.55 85.07 999999999 331.5 403.75 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 7611202101_1 CDM 761 RC 12021 HCPCS outpatient 425 318.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 361.55 85.07 999999999 331.5 403.75 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 7611202101_1 CDM 761 RC 12021 HCPCS outpatient 425 318.75 MOLINA MCAID MOLINA MCAID 354.45 83.4 999999999 331.5 403.75 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 7611202101_1 CDM 761 RC 12021 HCPCS outpatient 425 318.75 MOLINA MCR ADV MOLINA MCR ADV 378.25 89 999999999 331.5 403.75 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 7611202101_1 CDM 761 RC 12021 HCPCS outpatient 425 318.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 378.25 89 999999999 331.5 403.75 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 7611202101_1 CDM 761 RC 12021 HCPCS outpatient 425 318.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 378.25 89 999999999 331.5 403.75 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 7611202101_1 CDM 761 RC 12021 HCPCS outpatient 425 318.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 382.5 90 999999999 331.5 403.75 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 7611202101_1 CDM 761 RC 12021 HCPCS outpatient 425 318.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 403.75 95 999999999 331.5 403.75 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 7611202101_1 CDM 761 RC 12021 HCPCS outpatient 425 318.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 403.75 95 999999999 331.5 403.75 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 7611202101_1 CDM 761 RC 12021 HCPCS outpatient 425 318.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 378.25 89 999999999 331.5 403.75 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 7611202101_1 CDM 761 RC 12021 HCPCS outpatient 425 318.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 374 88 999999999 331.5 403.75 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 7611202101_1 CDM 761 RC 12021 HCPCS outpatient 425 318.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 378.25 89 999999999 331.5 403.75 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 7611202101_2 CDM 761 RC 12021 HCPCS outpatient 223 167.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 200.7 999999999 173.94 211.85 case rate TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 7611202101_2 CDM 761 RC 12021 HCPCS outpatient 223 167.25 AETNA MCR ADV AETNA MCR ADV 173.94 78 999999999 173.94 211.85 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 7611202101_2 CDM 761 RC 12021 HCPCS outpatient 223 167.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 195.28 87.57 999999999 173.94 211.85 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 7611202101_2 CDM 761 RC 12021 HCPCS outpatient 223 167.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 189.71 85.07 999999999 173.94 211.85 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 7611202101_2 CDM 761 RC 12021 HCPCS outpatient 223 167.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 189.71 85.07 999999999 173.94 211.85 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 7611202101_2 CDM 761 RC 12021 HCPCS outpatient 223 167.25 MOLINA MCAID MOLINA MCAID 185.98 83.4 999999999 173.94 211.85 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 7611202101_2 CDM 761 RC 12021 HCPCS outpatient 223 167.25 MOLINA MCR ADV MOLINA MCR ADV 198.47 89 999999999 173.94 211.85 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 7611202101_2 CDM 761 RC 12021 HCPCS outpatient 223 167.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 198.47 89 999999999 173.94 211.85 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 7611202101_2 CDM 761 RC 12021 HCPCS outpatient 223 167.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 198.47 89 999999999 173.94 211.85 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 7611202101_2 CDM 761 RC 12021 HCPCS outpatient 223 167.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 200.7 90 999999999 173.94 211.85 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 7611202101_2 CDM 761 RC 12021 HCPCS outpatient 223 167.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 211.85 95 999999999 173.94 211.85 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 7611202101_2 CDM 761 RC 12021 HCPCS outpatient 223 167.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 211.85 95 999999999 173.94 211.85 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 7611202101_2 CDM 761 RC 12021 HCPCS outpatient 223 167.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 198.47 89 999999999 173.94 211.85 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 7611202101_2 CDM 761 RC 12021 HCPCS outpatient 223 167.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 196.24 88 999999999 173.94 211.85 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 7611202101_2 CDM 761 RC 12021 HCPCS outpatient 223 167.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 198.47 89 999999999 173.94 211.85 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 762G037800_1 CDM 762 RC G0378 HCPCS outpatient 668 501 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 601.2 90 999999999 521.04 634.6 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 762G037800_1 CDM 762 RC G0378 HCPCS outpatient 668 501 AETNA MCR ADV AETNA MCR ADV 521.04 78 999999999 521.04 634.6 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 762G037800_1 CDM 762 RC G0378 HCPCS outpatient 668 501 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 584.97 87.57 999999999 521.04 634.6 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 762G037800_1 CDM 762 RC G0378 HCPCS outpatient 668 501 COORDINATED CARE MCAID COORDINATED CARE MCAID 568.27 85.07 999999999 521.04 634.6 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 762G037800_1 CDM 762 RC G0378 HCPCS outpatient 668 501 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 568.27 85.07 999999999 521.04 634.6 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 762G037800_1 CDM 762 RC G0378 HCPCS outpatient 668 501 MOLINA MCAID MOLINA MCAID 557.11 83.4 999999999 521.04 634.6 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 762G037800_1 CDM 762 RC G0378 HCPCS outpatient 668 501 MOLINA MCR ADV MOLINA MCR ADV 594.52 89 999999999 521.04 634.6 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 762G037800_1 CDM 762 RC G0378 HCPCS outpatient 668 501 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 594.52 89 999999999 521.04 634.6 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 762G037800_1 CDM 762 RC G0378 HCPCS outpatient 668 501 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 594.52 89 999999999 521.04 634.6 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 762G037800_1 CDM 762 RC G0378 HCPCS outpatient 668 501 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 601.2 90 999999999 521.04 634.6 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 762G037800_1 CDM 762 RC G0378 HCPCS outpatient 668 501 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 634.6 95 999999999 521.04 634.6 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 762G037800_1 CDM 762 RC G0378 HCPCS outpatient 668 501 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 634.6 95 999999999 521.04 634.6 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 762G037800_1 CDM 762 RC G0378 HCPCS outpatient 668 501 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 594.52 89 999999999 521.04 634.6 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 762G037800_1 CDM 762 RC G0378 HCPCS outpatient 668 501 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 587.84 88 999999999 521.04 634.6 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 762G037800_1 CDM 762 RC G0378 HCPCS outpatient 668 501 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 594.52 89 999999999 521.04 634.6 percent of total billed charges "ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), IMAGING SUPERVISION AND INTERPRETATION" 76942_1 CDM 402 RC 76942 HCPCS outpatient 250 187.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 225 90 999999999 195 237.5 percent of total billed charges "ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), IMAGING SUPERVISION AND INTERPRETATION" 76942_1 CDM 402 RC 76942 HCPCS outpatient 250 187.5 AETNA MCR ADV AETNA MCR ADV 195 78 999999999 195 237.5 percent of total billed charges "ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), IMAGING SUPERVISION AND INTERPRETATION" 76942_1 CDM 402 RC 76942 HCPCS outpatient 250 187.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 218.93 87.57 999999999 195 237.5 percent of total billed charges "ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), IMAGING SUPERVISION AND INTERPRETATION" 76942_1 CDM 402 RC 76942 HCPCS outpatient 250 187.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 212.68 85.07 999999999 195 237.5 percent of total billed charges "ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), IMAGING SUPERVISION AND INTERPRETATION" 76942_1 CDM 402 RC 76942 HCPCS outpatient 250 187.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 212.68 85.07 999999999 195 237.5 percent of total billed charges "ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), IMAGING SUPERVISION AND INTERPRETATION" 76942_1 CDM 402 RC 76942 HCPCS outpatient 250 187.5 MOLINA MCAID MOLINA MCAID 208.5 83.4 999999999 195 237.5 percent of total billed charges "ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), IMAGING SUPERVISION AND INTERPRETATION" 76942_1 CDM 402 RC 76942 HCPCS outpatient 250 187.5 MOLINA MCR ADV MOLINA MCR ADV 222.5 89 999999999 195 237.5 percent of total billed charges "ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), IMAGING SUPERVISION AND INTERPRETATION" 76942_1 CDM 402 RC 76942 HCPCS outpatient 250 187.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 222.5 89 999999999 195 237.5 percent of total billed charges "ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), IMAGING SUPERVISION AND INTERPRETATION" 76942_1 CDM 402 RC 76942 HCPCS outpatient 250 187.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 222.5 89 999999999 195 237.5 percent of total billed charges "ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), IMAGING SUPERVISION AND INTERPRETATION" 76942_1 CDM 402 RC 76942 HCPCS outpatient 250 187.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 225 90 999999999 195 237.5 percent of total billed charges "ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), IMAGING SUPERVISION AND INTERPRETATION" 76942_1 CDM 402 RC 76942 HCPCS outpatient 250 187.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 237.5 95 999999999 195 237.5 percent of total billed charges "ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), IMAGING SUPERVISION AND INTERPRETATION" 76942_1 CDM 402 RC 76942 HCPCS outpatient 250 187.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 237.5 95 999999999 195 237.5 percent of total billed charges "ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), IMAGING SUPERVISION AND INTERPRETATION" 76942_1 CDM 402 RC 76942 HCPCS outpatient 250 187.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 222.5 89 999999999 195 237.5 percent of total billed charges "ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), IMAGING SUPERVISION AND INTERPRETATION" 76942_1 CDM 402 RC 76942 HCPCS outpatient 250 187.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 220 88 999999999 195 237.5 percent of total billed charges "ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), IMAGING SUPERVISION AND INTERPRETATION" 76942_1 CDM 402 RC 76942 HCPCS outpatient 250 187.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 222.5 89 999999999 195 237.5 percent of total billed charges "FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 77002_1 CDM 320 RC 77002 HCPCS outpatient 100 75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 90 90 999999999 78 95 percent of total billed charges "FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 77002_1 CDM 320 RC 77002 HCPCS outpatient 100 75 AETNA MCR ADV AETNA MCR ADV 78 78 999999999 78 95 percent of total billed charges "FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 77002_1 CDM 320 RC 77002 HCPCS outpatient 100 75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 87.57 87.57 999999999 78 95 percent of total billed charges "FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 77002_1 CDM 320 RC 77002 HCPCS outpatient 100 75 COORDINATED CARE MCAID COORDINATED CARE MCAID 85.07 85.07 999999999 78 95 percent of total billed charges "FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 77002_1 CDM 320 RC 77002 HCPCS outpatient 100 75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 85.07 85.07 999999999 78 95 percent of total billed charges "FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 77002_1 CDM 320 RC 77002 HCPCS outpatient 100 75 MOLINA MCAID MOLINA MCAID 83.4 83.4 999999999 78 95 percent of total billed charges "FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 77002_1 CDM 320 RC 77002 HCPCS outpatient 100 75 MOLINA MCR ADV MOLINA MCR ADV 89 89 999999999 78 95 percent of total billed charges "FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 77002_1 CDM 320 RC 77002 HCPCS outpatient 100 75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 89 89 999999999 78 95 percent of total billed charges "FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 77002_1 CDM 320 RC 77002 HCPCS outpatient 100 75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 89 89 999999999 78 95 percent of total billed charges "FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 77002_1 CDM 320 RC 77002 HCPCS outpatient 100 75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 90 90 999999999 78 95 percent of total billed charges "FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 77002_1 CDM 320 RC 77002 HCPCS outpatient 100 75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 95 95 999999999 78 95 percent of total billed charges "FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 77002_1 CDM 320 RC 77002 HCPCS outpatient 100 75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 95 95 999999999 78 95 percent of total billed charges "FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 77002_1 CDM 320 RC 77002 HCPCS outpatient 100 75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 89 89 999999999 78 95 percent of total billed charges "FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 77002_1 CDM 320 RC 77002 HCPCS outpatient 100 75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 88 88 999999999 78 95 percent of total billed charges "FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 77002_1 CDM 320 RC 77002 HCPCS outpatient 100 75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 89 89 999999999 78 95 percent of total billed charges FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER TIP FOR SPINE OR PARASPINOUS DIAGNOSTIC OR THERAPEUTIC INJECTION PROCEDURES (EPIDURAL OR SUBARACHNOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 77003_1 CDM 320 RC 77003 HCPCS outpatient 120 90 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 108 90 999999999 93.6 114 percent of total billed charges FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER TIP FOR SPINE OR PARASPINOUS DIAGNOSTIC OR THERAPEUTIC INJECTION PROCEDURES (EPIDURAL OR SUBARACHNOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 77003_1 CDM 320 RC 77003 HCPCS outpatient 120 90 AETNA MCR ADV AETNA MCR ADV 93.6 78 999999999 93.6 114 percent of total billed charges FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER TIP FOR SPINE OR PARASPINOUS DIAGNOSTIC OR THERAPEUTIC INJECTION PROCEDURES (EPIDURAL OR SUBARACHNOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 77003_1 CDM 320 RC 77003 HCPCS outpatient 120 90 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 105.08 87.57 999999999 93.6 114 percent of total billed charges FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER TIP FOR SPINE OR PARASPINOUS DIAGNOSTIC OR THERAPEUTIC INJECTION PROCEDURES (EPIDURAL OR SUBARACHNOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 77003_1 CDM 320 RC 77003 HCPCS outpatient 120 90 COORDINATED CARE MCAID COORDINATED CARE MCAID 102.08 85.07 999999999 93.6 114 percent of total billed charges FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER TIP FOR SPINE OR PARASPINOUS DIAGNOSTIC OR THERAPEUTIC INJECTION PROCEDURES (EPIDURAL OR SUBARACHNOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 77003_1 CDM 320 RC 77003 HCPCS outpatient 120 90 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 102.08 85.07 999999999 93.6 114 percent of total billed charges FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER TIP FOR SPINE OR PARASPINOUS DIAGNOSTIC OR THERAPEUTIC INJECTION PROCEDURES (EPIDURAL OR SUBARACHNOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 77003_1 CDM 320 RC 77003 HCPCS outpatient 120 90 MOLINA MCAID MOLINA MCAID 100.08 83.4 999999999 93.6 114 percent of total billed charges FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER TIP FOR SPINE OR PARASPINOUS DIAGNOSTIC OR THERAPEUTIC INJECTION PROCEDURES (EPIDURAL OR SUBARACHNOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 77003_1 CDM 320 RC 77003 HCPCS outpatient 120 90 MOLINA MCR ADV MOLINA MCR ADV 106.8 89 999999999 93.6 114 percent of total billed charges FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER TIP FOR SPINE OR PARASPINOUS DIAGNOSTIC OR THERAPEUTIC INJECTION PROCEDURES (EPIDURAL OR SUBARACHNOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 77003_1 CDM 320 RC 77003 HCPCS outpatient 120 90 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 106.8 89 999999999 93.6 114 percent of total billed charges FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER TIP FOR SPINE OR PARASPINOUS DIAGNOSTIC OR THERAPEUTIC INJECTION PROCEDURES (EPIDURAL OR SUBARACHNOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 77003_1 CDM 320 RC 77003 HCPCS outpatient 120 90 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 106.8 89 999999999 93.6 114 percent of total billed charges FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER TIP FOR SPINE OR PARASPINOUS DIAGNOSTIC OR THERAPEUTIC INJECTION PROCEDURES (EPIDURAL OR SUBARACHNOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 77003_1 CDM 320 RC 77003 HCPCS outpatient 120 90 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 108 90 999999999 93.6 114 percent of total billed charges FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER TIP FOR SPINE OR PARASPINOUS DIAGNOSTIC OR THERAPEUTIC INJECTION PROCEDURES (EPIDURAL OR SUBARACHNOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 77003_1 CDM 320 RC 77003 HCPCS outpatient 120 90 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 114 95 999999999 93.6 114 percent of total billed charges FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER TIP FOR SPINE OR PARASPINOUS DIAGNOSTIC OR THERAPEUTIC INJECTION PROCEDURES (EPIDURAL OR SUBARACHNOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 77003_1 CDM 320 RC 77003 HCPCS outpatient 120 90 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 114 95 999999999 93.6 114 percent of total billed charges FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER TIP FOR SPINE OR PARASPINOUS DIAGNOSTIC OR THERAPEUTIC INJECTION PROCEDURES (EPIDURAL OR SUBARACHNOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 77003_1 CDM 320 RC 77003 HCPCS outpatient 120 90 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 106.8 89 999999999 93.6 114 percent of total billed charges FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER TIP FOR SPINE OR PARASPINOUS DIAGNOSTIC OR THERAPEUTIC INJECTION PROCEDURES (EPIDURAL OR SUBARACHNOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 77003_1 CDM 320 RC 77003 HCPCS outpatient 120 90 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 105.6 88 999999999 93.6 114 percent of total billed charges FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER TIP FOR SPINE OR PARASPINOUS DIAGNOSTIC OR THERAPEUTIC INJECTION PROCEDURES (EPIDURAL OR SUBARACHNOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 77003_1 CDM 320 RC 77003 HCPCS outpatient 120 90 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 106.8 89 999999999 93.6 114 percent of total billed charges "INTRAVENOUS INFUSION OR SUBCUTANEOUS INJECTION, CASIRIVIMAB AND IMDEVIMAB INCLUDES INFUSION OR INJECTION, AND POST ADMINISTRATION MONITORING, SUBSEQUENT REPEAT DOSES" 771M024001_1 CDM 771 RC M0240 HCPCS outpatient 500 375 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 450 90 999999999 390 475 percent of total billed charges "INTRAVENOUS INFUSION OR SUBCUTANEOUS INJECTION, CASIRIVIMAB AND IMDEVIMAB INCLUDES INFUSION OR INJECTION, AND POST ADMINISTRATION MONITORING, SUBSEQUENT REPEAT DOSES" 771M024001_1 CDM 771 RC M0240 HCPCS outpatient 500 375 AETNA MCR ADV AETNA MCR ADV 390 78 999999999 390 475 percent of total billed charges "INTRAVENOUS INFUSION OR SUBCUTANEOUS INJECTION, CASIRIVIMAB AND IMDEVIMAB INCLUDES INFUSION OR INJECTION, AND POST ADMINISTRATION MONITORING, SUBSEQUENT REPEAT DOSES" 771M024001_1 CDM 771 RC M0240 HCPCS outpatient 500 375 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 437.85 87.57 999999999 390 475 percent of total billed charges "INTRAVENOUS INFUSION OR SUBCUTANEOUS INJECTION, CASIRIVIMAB AND IMDEVIMAB INCLUDES INFUSION OR INJECTION, AND POST ADMINISTRATION MONITORING, SUBSEQUENT REPEAT DOSES" 771M024001_1 CDM 771 RC M0240 HCPCS outpatient 500 375 COORDINATED CARE MCAID COORDINATED CARE MCAID 425.35 85.07 999999999 390 475 percent of total billed charges "INTRAVENOUS INFUSION OR SUBCUTANEOUS INJECTION, CASIRIVIMAB AND IMDEVIMAB INCLUDES INFUSION OR INJECTION, AND POST ADMINISTRATION MONITORING, SUBSEQUENT REPEAT DOSES" 771M024001_1 CDM 771 RC M0240 HCPCS outpatient 500 375 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 425.35 85.07 999999999 390 475 percent of total billed charges "INTRAVENOUS INFUSION OR SUBCUTANEOUS INJECTION, CASIRIVIMAB AND IMDEVIMAB INCLUDES INFUSION OR INJECTION, AND POST ADMINISTRATION MONITORING, SUBSEQUENT REPEAT DOSES" 771M024001_1 CDM 771 RC M0240 HCPCS outpatient 500 375 MOLINA MCAID MOLINA MCAID 417 83.4 999999999 390 475 percent of total billed charges "INTRAVENOUS INFUSION OR SUBCUTANEOUS INJECTION, CASIRIVIMAB AND IMDEVIMAB INCLUDES INFUSION OR INJECTION, AND POST ADMINISTRATION MONITORING, SUBSEQUENT REPEAT DOSES" 771M024001_1 CDM 771 RC M0240 HCPCS outpatient 500 375 MOLINA MCR ADV MOLINA MCR ADV 445 89 999999999 390 475 percent of total billed charges "INTRAVENOUS INFUSION OR SUBCUTANEOUS INJECTION, CASIRIVIMAB AND IMDEVIMAB INCLUDES INFUSION OR INJECTION, AND POST ADMINISTRATION MONITORING, SUBSEQUENT REPEAT DOSES" 771M024001_1 CDM 771 RC M0240 HCPCS outpatient 500 375 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 445 89 999999999 390 475 percent of total billed charges "INTRAVENOUS INFUSION OR SUBCUTANEOUS INJECTION, CASIRIVIMAB AND IMDEVIMAB INCLUDES INFUSION OR INJECTION, AND POST ADMINISTRATION MONITORING, SUBSEQUENT REPEAT DOSES" 771M024001_1 CDM 771 RC M0240 HCPCS outpatient 500 375 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 445 89 999999999 390 475 percent of total billed charges "INTRAVENOUS INFUSION OR SUBCUTANEOUS INJECTION, CASIRIVIMAB AND IMDEVIMAB INCLUDES INFUSION OR INJECTION, AND POST ADMINISTRATION MONITORING, SUBSEQUENT REPEAT DOSES" 771M024001_1 CDM 771 RC M0240 HCPCS outpatient 500 375 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 450 90 999999999 390 475 percent of total billed charges "INTRAVENOUS INFUSION OR SUBCUTANEOUS INJECTION, CASIRIVIMAB AND IMDEVIMAB INCLUDES INFUSION OR INJECTION, AND POST ADMINISTRATION MONITORING, SUBSEQUENT REPEAT DOSES" 771M024001_1 CDM 771 RC M0240 HCPCS outpatient 500 375 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 475 95 999999999 390 475 percent of total billed charges "INTRAVENOUS INFUSION OR SUBCUTANEOUS INJECTION, CASIRIVIMAB AND IMDEVIMAB INCLUDES INFUSION OR INJECTION, AND POST ADMINISTRATION MONITORING, SUBSEQUENT REPEAT DOSES" 771M024001_1 CDM 771 RC M0240 HCPCS outpatient 500 375 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 475 95 999999999 390 475 percent of total billed charges "INTRAVENOUS INFUSION OR SUBCUTANEOUS INJECTION, CASIRIVIMAB AND IMDEVIMAB INCLUDES INFUSION OR INJECTION, AND POST ADMINISTRATION MONITORING, SUBSEQUENT REPEAT DOSES" 771M024001_1 CDM 771 RC M0240 HCPCS outpatient 500 375 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 445 89 999999999 390 475 percent of total billed charges "INTRAVENOUS INFUSION OR SUBCUTANEOUS INJECTION, CASIRIVIMAB AND IMDEVIMAB INCLUDES INFUSION OR INJECTION, AND POST ADMINISTRATION MONITORING, SUBSEQUENT REPEAT DOSES" 771M024001_1 CDM 771 RC M0240 HCPCS outpatient 500 375 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 440 88 999999999 390 475 percent of total billed charges "INTRAVENOUS INFUSION OR SUBCUTANEOUS INJECTION, CASIRIVIMAB AND IMDEVIMAB INCLUDES INFUSION OR INJECTION, AND POST ADMINISTRATION MONITORING, SUBSEQUENT REPEAT DOSES" 771M024001_1 CDM 771 RC M0240 HCPCS outpatient 500 375 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 445 89 999999999 390 475 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITH MICROSCOPY" 81000_3 CDM 300 RC 81000 HCPCS outpatient 12.06 9.05 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 10.85 90 999999999 9.41 11.46 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITH MICROSCOPY" 81000_3 CDM 300 RC 81000 HCPCS outpatient 12.06 9.05 AETNA MCR ADV AETNA MCR ADV 9.41 78 999999999 9.41 11.46 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITH MICROSCOPY" 81000_3 CDM 300 RC 81000 HCPCS outpatient 12.06 9.05 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 10.56 87.57 999999999 9.41 11.46 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITH MICROSCOPY" 81000_3 CDM 300 RC 81000 HCPCS outpatient 12.06 9.05 COORDINATED CARE MCAID COORDINATED CARE MCAID 10.26 85.07 999999999 9.41 11.46 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITH MICROSCOPY" 81000_3 CDM 300 RC 81000 HCPCS outpatient 12.06 9.05 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 10.26 85.07 999999999 9.41 11.46 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITH MICROSCOPY" 81000_3 CDM 300 RC 81000 HCPCS outpatient 12.06 9.05 MOLINA MCAID MOLINA MCAID 10.06 83.4 999999999 9.41 11.46 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITH MICROSCOPY" 81000_3 CDM 300 RC 81000 HCPCS outpatient 12.06 9.05 MOLINA MCR ADV MOLINA MCR ADV 10.73 89 999999999 9.41 11.46 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITH MICROSCOPY" 81000_3 CDM 300 RC 81000 HCPCS outpatient 12.06 9.05 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 10.73 89 999999999 9.41 11.46 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITH MICROSCOPY" 81000_3 CDM 300 RC 81000 HCPCS outpatient 12.06 9.05 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 10.73 89 999999999 9.41 11.46 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITH MICROSCOPY" 81000_3 CDM 300 RC 81000 HCPCS outpatient 12.06 9.05 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 10.85 90 999999999 9.41 11.46 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITH MICROSCOPY" 81000_3 CDM 300 RC 81000 HCPCS outpatient 12.06 9.05 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 11.46 95 999999999 9.41 11.46 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITH MICROSCOPY" 81000_3 CDM 300 RC 81000 HCPCS outpatient 12.06 9.05 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 11.46 95 999999999 9.41 11.46 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITH MICROSCOPY" 81000_3 CDM 300 RC 81000 HCPCS outpatient 12.06 9.05 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 10.73 89 999999999 9.41 11.46 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITH MICROSCOPY" 81000_3 CDM 300 RC 81000 HCPCS outpatient 12.06 9.05 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 10.61 88 999999999 9.41 11.46 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITH MICROSCOPY" 81000_3 CDM 300 RC 81000 HCPCS outpatient 12.06 9.05 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 10.73 89 999999999 9.41 11.46 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY" 81001_3 CDM 307 RC 81001 HCPCS outpatient 9.51 7.13 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 8.56 90 999999999 7.42 9.03 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY" 81001_3 CDM 307 RC 81001 HCPCS outpatient 9.51 7.13 AETNA MCR ADV AETNA MCR ADV 7.42 78 999999999 7.42 9.03 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY" 81001_3 CDM 307 RC 81001 HCPCS outpatient 9.51 7.13 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 8.33 87.57 999999999 7.42 9.03 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY" 81001_3 CDM 307 RC 81001 HCPCS outpatient 9.51 7.13 COORDINATED CARE MCAID COORDINATED CARE MCAID 8.09 85.07 999999999 7.42 9.03 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY" 81001_3 CDM 307 RC 81001 HCPCS outpatient 9.51 7.13 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 8.09 85.07 999999999 7.42 9.03 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY" 81001_3 CDM 307 RC 81001 HCPCS outpatient 9.51 7.13 MOLINA MCAID MOLINA MCAID 7.93 83.4 999999999 7.42 9.03 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY" 81001_3 CDM 307 RC 81001 HCPCS outpatient 9.51 7.13 MOLINA MCR ADV MOLINA MCR ADV 8.46 89 999999999 7.42 9.03 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY" 81001_3 CDM 307 RC 81001 HCPCS outpatient 9.51 7.13 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 8.46 89 999999999 7.42 9.03 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY" 81001_3 CDM 307 RC 81001 HCPCS outpatient 9.51 7.13 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 8.46 89 999999999 7.42 9.03 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY" 81001_3 CDM 307 RC 81001 HCPCS outpatient 9.51 7.13 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 8.56 90 999999999 7.42 9.03 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY" 81001_3 CDM 307 RC 81001 HCPCS outpatient 9.51 7.13 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 9.03 95 999999999 7.42 9.03 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY" 81001_3 CDM 307 RC 81001 HCPCS outpatient 9.51 7.13 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 9.03 95 999999999 7.42 9.03 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY" 81001_3 CDM 307 RC 81001 HCPCS outpatient 9.51 7.13 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 8.46 89 999999999 7.42 9.03 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY" 81001_3 CDM 307 RC 81001 HCPCS outpatient 9.51 7.13 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 8.37 88 999999999 7.42 9.03 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY" 81001_3 CDM 307 RC 81001 HCPCS outpatient 9.51 7.13 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 8.46 89 999999999 7.42 9.03 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITHOUT MICROSCOPY" 81002_1 CDM 300 RC 81002 HCPCS outpatient 48 36 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 43.2 90 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITHOUT MICROSCOPY" 81002_1 CDM 300 RC 81002 HCPCS outpatient 48 36 AETNA MCR ADV AETNA MCR ADV 37.44 78 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITHOUT MICROSCOPY" 81002_1 CDM 300 RC 81002 HCPCS outpatient 48 36 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 42.03 87.57 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITHOUT MICROSCOPY" 81002_1 CDM 300 RC 81002 HCPCS outpatient 48 36 COORDINATED CARE MCAID COORDINATED CARE MCAID 40.83 85.07 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITHOUT MICROSCOPY" 81002_1 CDM 300 RC 81002 HCPCS outpatient 48 36 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 40.83 85.07 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITHOUT MICROSCOPY" 81002_1 CDM 300 RC 81002 HCPCS outpatient 48 36 MOLINA MCAID MOLINA MCAID 40.03 83.4 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITHOUT MICROSCOPY" 81002_1 CDM 300 RC 81002 HCPCS outpatient 48 36 MOLINA MCR ADV MOLINA MCR ADV 42.72 89 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITHOUT MICROSCOPY" 81002_1 CDM 300 RC 81002 HCPCS outpatient 48 36 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 42.72 89 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITHOUT MICROSCOPY" 81002_1 CDM 300 RC 81002 HCPCS outpatient 48 36 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 42.72 89 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITHOUT MICROSCOPY" 81002_1 CDM 300 RC 81002 HCPCS outpatient 48 36 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 43.2 90 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITHOUT MICROSCOPY" 81002_1 CDM 300 RC 81002 HCPCS outpatient 48 36 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 45.6 95 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITHOUT MICROSCOPY" 81002_1 CDM 300 RC 81002 HCPCS outpatient 48 36 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 45.6 95 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITHOUT MICROSCOPY" 81002_1 CDM 300 RC 81002 HCPCS outpatient 48 36 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 42.72 89 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITHOUT MICROSCOPY" 81002_1 CDM 300 RC 81002 HCPCS outpatient 48 36 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 42.24 88 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITHOUT MICROSCOPY" 81002_1 CDM 300 RC 81002 HCPCS outpatient 48 36 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 42.72 89 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITHOUT MICROSCOPY" 81002_3 CDM 300 RC 81002 HCPCS outpatient 48 36 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 43.2 90 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITHOUT MICROSCOPY" 81002_3 CDM 300 RC 81002 HCPCS outpatient 48 36 AETNA MCR ADV AETNA MCR ADV 37.44 78 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITHOUT MICROSCOPY" 81002_3 CDM 300 RC 81002 HCPCS outpatient 48 36 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 42.03 87.57 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITHOUT MICROSCOPY" 81002_3 CDM 300 RC 81002 HCPCS outpatient 48 36 COORDINATED CARE MCAID COORDINATED CARE MCAID 40.83 85.07 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITHOUT MICROSCOPY" 81002_3 CDM 300 RC 81002 HCPCS outpatient 48 36 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 40.83 85.07 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITHOUT MICROSCOPY" 81002_3 CDM 300 RC 81002 HCPCS outpatient 48 36 MOLINA MCAID MOLINA MCAID 40.03 83.4 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITHOUT MICROSCOPY" 81002_3 CDM 300 RC 81002 HCPCS outpatient 48 36 MOLINA MCR ADV MOLINA MCR ADV 42.72 89 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITHOUT MICROSCOPY" 81002_3 CDM 300 RC 81002 HCPCS outpatient 48 36 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 42.72 89 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITHOUT MICROSCOPY" 81002_3 CDM 300 RC 81002 HCPCS outpatient 48 36 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 42.72 89 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITHOUT MICROSCOPY" 81002_3 CDM 300 RC 81002 HCPCS outpatient 48 36 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 43.2 90 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITHOUT MICROSCOPY" 81002_3 CDM 300 RC 81002 HCPCS outpatient 48 36 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 45.6 95 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITHOUT MICROSCOPY" 81002_3 CDM 300 RC 81002 HCPCS outpatient 48 36 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 45.6 95 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITHOUT MICROSCOPY" 81002_3 CDM 300 RC 81002 HCPCS outpatient 48 36 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 42.72 89 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITHOUT MICROSCOPY" 81002_3 CDM 300 RC 81002 HCPCS outpatient 48 36 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 42.24 88 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITHOUT MICROSCOPY" 81002_3 CDM 300 RC 81002 HCPCS outpatient 48 36 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 42.72 89 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 81003H_1 CDM 307 RC 81003 HCPCS outpatient 48 36 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 43.2 90 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 81003H_1 CDM 307 RC 81003 HCPCS outpatient 48 36 AETNA MCR ADV AETNA MCR ADV 37.44 78 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 81003H_1 CDM 307 RC 81003 HCPCS outpatient 48 36 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 42.03 87.57 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 81003H_1 CDM 307 RC 81003 HCPCS outpatient 48 36 COORDINATED CARE MCAID COORDINATED CARE MCAID 40.83 85.07 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 81003H_1 CDM 307 RC 81003 HCPCS outpatient 48 36 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 40.83 85.07 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 81003H_1 CDM 307 RC 81003 HCPCS outpatient 48 36 MOLINA MCAID MOLINA MCAID 40.03 83.4 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 81003H_1 CDM 307 RC 81003 HCPCS outpatient 48 36 MOLINA MCR ADV MOLINA MCR ADV 42.72 89 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 81003H_1 CDM 307 RC 81003 HCPCS outpatient 48 36 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 42.72 89 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 81003H_1 CDM 307 RC 81003 HCPCS outpatient 48 36 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 42.72 89 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 81003H_1 CDM 307 RC 81003 HCPCS outpatient 48 36 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 43.2 90 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 81003H_1 CDM 307 RC 81003 HCPCS outpatient 48 36 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 45.6 95 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 81003H_1 CDM 307 RC 81003 HCPCS outpatient 48 36 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 45.6 95 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 81003H_1 CDM 307 RC 81003 HCPCS outpatient 48 36 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 42.72 89 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 81003H_1 CDM 307 RC 81003 HCPCS outpatient 48 36 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 42.24 88 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 81003H_1 CDM 307 RC 81003 HCPCS outpatient 48 36 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 42.72 89 999999999 37.44 45.6 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 81003H_3 CDM 307 RC 81003 HCPCS outpatient 6.75 5.06 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 6.08 90 999999999 5.27 6.41 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 81003H_3 CDM 307 RC 81003 HCPCS outpatient 6.75 5.06 AETNA MCR ADV AETNA MCR ADV 5.27 78 999999999 5.27 6.41 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 81003H_3 CDM 307 RC 81003 HCPCS outpatient 6.75 5.06 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 5.91 87.57 999999999 5.27 6.41 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 81003H_3 CDM 307 RC 81003 HCPCS outpatient 6.75 5.06 COORDINATED CARE MCAID COORDINATED CARE MCAID 5.74 85.07 999999999 5.27 6.41 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 81003H_3 CDM 307 RC 81003 HCPCS outpatient 6.75 5.06 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 5.74 85.07 999999999 5.27 6.41 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 81003H_3 CDM 307 RC 81003 HCPCS outpatient 6.75 5.06 MOLINA MCAID MOLINA MCAID 5.63 83.4 999999999 5.27 6.41 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 81003H_3 CDM 307 RC 81003 HCPCS outpatient 6.75 5.06 MOLINA MCR ADV MOLINA MCR ADV 6.01 89 999999999 5.27 6.41 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 81003H_3 CDM 307 RC 81003 HCPCS outpatient 6.75 5.06 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 6.01 89 999999999 5.27 6.41 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 81003H_3 CDM 307 RC 81003 HCPCS outpatient 6.75 5.06 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 6.01 89 999999999 5.27 6.41 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 81003H_3 CDM 307 RC 81003 HCPCS outpatient 6.75 5.06 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 6.08 90 999999999 5.27 6.41 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 81003H_3 CDM 307 RC 81003 HCPCS outpatient 6.75 5.06 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 6.41 95 999999999 5.27 6.41 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 81003H_3 CDM 307 RC 81003 HCPCS outpatient 6.75 5.06 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 6.41 95 999999999 5.27 6.41 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 81003H_3 CDM 307 RC 81003 HCPCS outpatient 6.75 5.06 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 6.01 89 999999999 5.27 6.41 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 81003H_3 CDM 307 RC 81003 HCPCS outpatient 6.75 5.06 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 5.94 88 999999999 5.27 6.41 percent of total billed charges "URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY" 81003H_3 CDM 307 RC 81003 HCPCS outpatient 6.75 5.06 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 6.01 89 999999999 5.27 6.41 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 81005A_1 CDM 307 RC 81005 HCPCS outpatient 56 42 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50.4 90 999999999 43.68 53.2 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 81005A_1 CDM 307 RC 81005 HCPCS outpatient 56 42 AETNA MCR ADV AETNA MCR ADV 43.68 78 999999999 43.68 53.2 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 81005A_1 CDM 307 RC 81005 HCPCS outpatient 56 42 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 49.04 87.57 999999999 43.68 53.2 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 81005A_1 CDM 307 RC 81005 HCPCS outpatient 56 42 COORDINATED CARE MCAID COORDINATED CARE MCAID 47.64 85.07 999999999 43.68 53.2 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 81005A_1 CDM 307 RC 81005 HCPCS outpatient 56 42 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 47.64 85.07 999999999 43.68 53.2 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 81005A_1 CDM 307 RC 81005 HCPCS outpatient 56 42 MOLINA MCAID MOLINA MCAID 46.7 83.4 999999999 43.68 53.2 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 81005A_1 CDM 307 RC 81005 HCPCS outpatient 56 42 MOLINA MCR ADV MOLINA MCR ADV 49.84 89 999999999 43.68 53.2 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 81005A_1 CDM 307 RC 81005 HCPCS outpatient 56 42 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 49.84 89 999999999 43.68 53.2 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 81005A_1 CDM 307 RC 81005 HCPCS outpatient 56 42 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 49.84 89 999999999 43.68 53.2 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 81005A_1 CDM 307 RC 81005 HCPCS outpatient 56 42 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50.4 90 999999999 43.68 53.2 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 81005A_1 CDM 307 RC 81005 HCPCS outpatient 56 42 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 53.2 95 999999999 43.68 53.2 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 81005A_1 CDM 307 RC 81005 HCPCS outpatient 56 42 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 53.2 95 999999999 43.68 53.2 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 81005A_1 CDM 307 RC 81005 HCPCS outpatient 56 42 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 49.84 89 999999999 43.68 53.2 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 81005A_1 CDM 307 RC 81005 HCPCS outpatient 56 42 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 49.28 88 999999999 43.68 53.2 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 81005A_1 CDM 307 RC 81005 HCPCS outpatient 56 42 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 49.84 89 999999999 43.68 53.2 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 81005A_3 CDM 307 RC 81005 HCPCS outpatient 56 42 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50.4 90 999999999 43.68 53.2 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 81005A_3 CDM 307 RC 81005 HCPCS outpatient 56 42 AETNA MCR ADV AETNA MCR ADV 43.68 78 999999999 43.68 53.2 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 81005A_3 CDM 307 RC 81005 HCPCS outpatient 56 42 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 49.04 87.57 999999999 43.68 53.2 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 81005A_3 CDM 307 RC 81005 HCPCS outpatient 56 42 COORDINATED CARE MCAID COORDINATED CARE MCAID 47.64 85.07 999999999 43.68 53.2 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 81005A_3 CDM 307 RC 81005 HCPCS outpatient 56 42 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 47.64 85.07 999999999 43.68 53.2 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 81005A_3 CDM 307 RC 81005 HCPCS outpatient 56 42 MOLINA MCAID MOLINA MCAID 46.7 83.4 999999999 43.68 53.2 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 81005A_3 CDM 307 RC 81005 HCPCS outpatient 56 42 MOLINA MCR ADV MOLINA MCR ADV 49.84 89 999999999 43.68 53.2 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 81005A_3 CDM 307 RC 81005 HCPCS outpatient 56 42 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 49.84 89 999999999 43.68 53.2 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 81005A_3 CDM 307 RC 81005 HCPCS outpatient 56 42 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 49.84 89 999999999 43.68 53.2 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 81005A_3 CDM 307 RC 81005 HCPCS outpatient 56 42 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50.4 90 999999999 43.68 53.2 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 81005A_3 CDM 307 RC 81005 HCPCS outpatient 56 42 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 53.2 95 999999999 43.68 53.2 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 81005A_3 CDM 307 RC 81005 HCPCS outpatient 56 42 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 53.2 95 999999999 43.68 53.2 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 81005A_3 CDM 307 RC 81005 HCPCS outpatient 56 42 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 49.84 89 999999999 43.68 53.2 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 81005A_3 CDM 307 RC 81005 HCPCS outpatient 56 42 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 49.28 88 999999999 43.68 53.2 percent of total billed charges "URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT IMMUNOASSAYS" 81005A_3 CDM 307 RC 81005 HCPCS outpatient 56 42 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 49.84 89 999999999 43.68 53.2 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025_1 CDM 307 RC 81025 HCPCS outpatient 79 59.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 71.1 90 999999999 61.62 75.05 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025_1 CDM 307 RC 81025 HCPCS outpatient 79 59.25 AETNA MCR ADV AETNA MCR ADV 61.62 78 999999999 61.62 75.05 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025_1 CDM 307 RC 81025 HCPCS outpatient 79 59.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 69.18 87.57 999999999 61.62 75.05 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025_1 CDM 307 RC 81025 HCPCS outpatient 79 59.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 67.21 85.07 999999999 61.62 75.05 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025_1 CDM 307 RC 81025 HCPCS outpatient 79 59.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 67.21 85.07 999999999 61.62 75.05 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025_1 CDM 307 RC 81025 HCPCS outpatient 79 59.25 MOLINA MCAID MOLINA MCAID 65.89 83.4 999999999 61.62 75.05 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025_1 CDM 307 RC 81025 HCPCS outpatient 79 59.25 MOLINA MCR ADV MOLINA MCR ADV 70.31 89 999999999 61.62 75.05 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025_1 CDM 307 RC 81025 HCPCS outpatient 79 59.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 70.31 89 999999999 61.62 75.05 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025_1 CDM 307 RC 81025 HCPCS outpatient 79 59.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 70.31 89 999999999 61.62 75.05 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025_1 CDM 307 RC 81025 HCPCS outpatient 79 59.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 71.1 90 999999999 61.62 75.05 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025_1 CDM 307 RC 81025 HCPCS outpatient 79 59.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 75.05 95 999999999 61.62 75.05 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025_1 CDM 307 RC 81025 HCPCS outpatient 79 59.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 75.05 95 999999999 61.62 75.05 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025_1 CDM 307 RC 81025 HCPCS outpatient 79 59.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 70.31 89 999999999 61.62 75.05 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025_1 CDM 307 RC 81025 HCPCS outpatient 79 59.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 69.52 88 999999999 61.62 75.05 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025_1 CDM 307 RC 81025 HCPCS outpatient 79 59.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 70.31 89 999999999 61.62 75.05 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025A_1 CDM 307 RC 81025 HCPCS outpatient 115 86.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 103.5 90 999999999 89.7 109.25 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025A_1 CDM 307 RC 81025 HCPCS outpatient 115 86.25 AETNA MCR ADV AETNA MCR ADV 89.7 78 999999999 89.7 109.25 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025A_1 CDM 307 RC 81025 HCPCS outpatient 115 86.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 100.71 87.57 999999999 89.7 109.25 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025A_1 CDM 307 RC 81025 HCPCS outpatient 115 86.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 97.83 85.07 999999999 89.7 109.25 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025A_1 CDM 307 RC 81025 HCPCS outpatient 115 86.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 97.83 85.07 999999999 89.7 109.25 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025A_1 CDM 307 RC 81025 HCPCS outpatient 115 86.25 MOLINA MCAID MOLINA MCAID 95.91 83.4 999999999 89.7 109.25 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025A_1 CDM 307 RC 81025 HCPCS outpatient 115 86.25 MOLINA MCR ADV MOLINA MCR ADV 102.35 89 999999999 89.7 109.25 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025A_1 CDM 307 RC 81025 HCPCS outpatient 115 86.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 102.35 89 999999999 89.7 109.25 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025A_1 CDM 307 RC 81025 HCPCS outpatient 115 86.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 102.35 89 999999999 89.7 109.25 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025A_1 CDM 307 RC 81025 HCPCS outpatient 115 86.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 103.5 90 999999999 89.7 109.25 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025A_1 CDM 307 RC 81025 HCPCS outpatient 115 86.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 109.25 95 999999999 89.7 109.25 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025A_1 CDM 307 RC 81025 HCPCS outpatient 115 86.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 109.25 95 999999999 89.7 109.25 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025A_1 CDM 307 RC 81025 HCPCS outpatient 115 86.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 102.35 89 999999999 89.7 109.25 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025A_1 CDM 307 RC 81025 HCPCS outpatient 115 86.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 101.2 88 999999999 89.7 109.25 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025A_1 CDM 307 RC 81025 HCPCS outpatient 115 86.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 102.35 89 999999999 89.7 109.25 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025A_3 CDM 307 RC 81025 HCPCS outpatient 115 86.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 103.5 90 999999999 89.7 109.25 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025A_3 CDM 307 RC 81025 HCPCS outpatient 115 86.25 AETNA MCR ADV AETNA MCR ADV 89.7 78 999999999 89.7 109.25 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025A_3 CDM 307 RC 81025 HCPCS outpatient 115 86.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 100.71 87.57 999999999 89.7 109.25 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025A_3 CDM 307 RC 81025 HCPCS outpatient 115 86.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 97.83 85.07 999999999 89.7 109.25 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025A_3 CDM 307 RC 81025 HCPCS outpatient 115 86.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 97.83 85.07 999999999 89.7 109.25 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025A_3 CDM 307 RC 81025 HCPCS outpatient 115 86.25 MOLINA MCAID MOLINA MCAID 95.91 83.4 999999999 89.7 109.25 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025A_3 CDM 307 RC 81025 HCPCS outpatient 115 86.25 MOLINA MCR ADV MOLINA MCR ADV 102.35 89 999999999 89.7 109.25 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025A_3 CDM 307 RC 81025 HCPCS outpatient 115 86.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 102.35 89 999999999 89.7 109.25 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025A_3 CDM 307 RC 81025 HCPCS outpatient 115 86.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 102.35 89 999999999 89.7 109.25 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025A_3 CDM 307 RC 81025 HCPCS outpatient 115 86.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 103.5 90 999999999 89.7 109.25 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025A_3 CDM 307 RC 81025 HCPCS outpatient 115 86.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 109.25 95 999999999 89.7 109.25 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025A_3 CDM 307 RC 81025 HCPCS outpatient 115 86.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 109.25 95 999999999 89.7 109.25 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025A_3 CDM 307 RC 81025 HCPCS outpatient 115 86.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 102.35 89 999999999 89.7 109.25 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025A_3 CDM 307 RC 81025 HCPCS outpatient 115 86.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 101.2 88 999999999 89.7 109.25 percent of total billed charges "URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS" 81025A_3 CDM 307 RC 81025 HCPCS outpatient 115 86.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 102.35 89 999999999 89.7 109.25 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 82270A_1 CDM 309 RC 82270 HCPCS outpatient 62 46.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 55.8 90 999999999 48.36 58.9 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 82270A_1 CDM 309 RC 82270 HCPCS outpatient 62 46.5 AETNA MCR ADV AETNA MCR ADV 48.36 78 999999999 48.36 58.9 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 82270A_1 CDM 309 RC 82270 HCPCS outpatient 62 46.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 54.29 87.57 999999999 48.36 58.9 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 82270A_1 CDM 309 RC 82270 HCPCS outpatient 62 46.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 52.74 85.07 999999999 48.36 58.9 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 82270A_1 CDM 309 RC 82270 HCPCS outpatient 62 46.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 52.74 85.07 999999999 48.36 58.9 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 82270A_1 CDM 309 RC 82270 HCPCS outpatient 62 46.5 MOLINA MCAID MOLINA MCAID 51.71 83.4 999999999 48.36 58.9 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 82270A_1 CDM 309 RC 82270 HCPCS outpatient 62 46.5 MOLINA MCR ADV MOLINA MCR ADV 55.18 89 999999999 48.36 58.9 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 82270A_1 CDM 309 RC 82270 HCPCS outpatient 62 46.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 55.18 89 999999999 48.36 58.9 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 82270A_1 CDM 309 RC 82270 HCPCS outpatient 62 46.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 55.18 89 999999999 48.36 58.9 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 82270A_1 CDM 309 RC 82270 HCPCS outpatient 62 46.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 55.8 90 999999999 48.36 58.9 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 82270A_1 CDM 309 RC 82270 HCPCS outpatient 62 46.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 58.9 95 999999999 48.36 58.9 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 82270A_1 CDM 309 RC 82270 HCPCS outpatient 62 46.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 58.9 95 999999999 48.36 58.9 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 82270A_1 CDM 309 RC 82270 HCPCS outpatient 62 46.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 55.18 89 999999999 48.36 58.9 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 82270A_1 CDM 309 RC 82270 HCPCS outpatient 62 46.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 54.56 88 999999999 48.36 58.9 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 82270A_1 CDM 309 RC 82270 HCPCS outpatient 62 46.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 55.18 89 999999999 48.36 58.9 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 82270A_3 CDM 309 RC 82270 HCPCS outpatient 13.14 9.86 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 11.83 90 999999999 10.25 12.48 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 82270A_3 CDM 309 RC 82270 HCPCS outpatient 13.14 9.86 AETNA MCR ADV AETNA MCR ADV 10.25 78 999999999 10.25 12.48 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 82270A_3 CDM 309 RC 82270 HCPCS outpatient 13.14 9.86 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 11.51 87.57 999999999 10.25 12.48 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 82270A_3 CDM 309 RC 82270 HCPCS outpatient 13.14 9.86 COORDINATED CARE MCAID COORDINATED CARE MCAID 11.18 85.07 999999999 10.25 12.48 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 82270A_3 CDM 309 RC 82270 HCPCS outpatient 13.14 9.86 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 11.18 85.07 999999999 10.25 12.48 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 82270A_3 CDM 309 RC 82270 HCPCS outpatient 13.14 9.86 MOLINA MCAID MOLINA MCAID 10.96 83.4 999999999 10.25 12.48 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 82270A_3 CDM 309 RC 82270 HCPCS outpatient 13.14 9.86 MOLINA MCR ADV MOLINA MCR ADV 11.69 89 999999999 10.25 12.48 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 82270A_3 CDM 309 RC 82270 HCPCS outpatient 13.14 9.86 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 11.69 89 999999999 10.25 12.48 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 82270A_3 CDM 309 RC 82270 HCPCS outpatient 13.14 9.86 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 11.69 89 999999999 10.25 12.48 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 82270A_3 CDM 309 RC 82270 HCPCS outpatient 13.14 9.86 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 11.83 90 999999999 10.25 12.48 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 82270A_3 CDM 309 RC 82270 HCPCS outpatient 13.14 9.86 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 12.48 95 999999999 10.25 12.48 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 82270A_3 CDM 309 RC 82270 HCPCS outpatient 13.14 9.86 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 12.48 95 999999999 10.25 12.48 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 82270A_3 CDM 309 RC 82270 HCPCS outpatient 13.14 9.86 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 11.69 89 999999999 10.25 12.48 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 82270A_3 CDM 309 RC 82270 HCPCS outpatient 13.14 9.86 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 11.56 88 999999999 10.25 12.48 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION)" 82270A_3 CDM 309 RC 82270 HCPCS outpatient 13.14 9.86 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 11.69 89 999999999 10.25 12.48 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS, PERFORMED FOR OTHER THAN COLORECTAL NEOPLASM SCREENING" 82272_1 CDM 309 RC 82272 HCPCS outpatient 53 39.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 47.7 90 999999999 41.34 50.35 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS, PERFORMED FOR OTHER THAN COLORECTAL NEOPLASM SCREENING" 82272_1 CDM 309 RC 82272 HCPCS outpatient 53 39.75 AETNA MCR ADV AETNA MCR ADV 41.34 78 999999999 41.34 50.35 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS, PERFORMED FOR OTHER THAN COLORECTAL NEOPLASM SCREENING" 82272_1 CDM 309 RC 82272 HCPCS outpatient 53 39.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 46.41 87.57 999999999 41.34 50.35 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS, PERFORMED FOR OTHER THAN COLORECTAL NEOPLASM SCREENING" 82272_1 CDM 309 RC 82272 HCPCS outpatient 53 39.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 45.09 85.07 999999999 41.34 50.35 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS, PERFORMED FOR OTHER THAN COLORECTAL NEOPLASM SCREENING" 82272_1 CDM 309 RC 82272 HCPCS outpatient 53 39.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 45.09 85.07 999999999 41.34 50.35 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS, PERFORMED FOR OTHER THAN COLORECTAL NEOPLASM SCREENING" 82272_1 CDM 309 RC 82272 HCPCS outpatient 53 39.75 MOLINA MCAID MOLINA MCAID 44.2 83.4 999999999 41.34 50.35 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS, PERFORMED FOR OTHER THAN COLORECTAL NEOPLASM SCREENING" 82272_1 CDM 309 RC 82272 HCPCS outpatient 53 39.75 MOLINA MCR ADV MOLINA MCR ADV 47.17 89 999999999 41.34 50.35 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS, PERFORMED FOR OTHER THAN COLORECTAL NEOPLASM SCREENING" 82272_1 CDM 309 RC 82272 HCPCS outpatient 53 39.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 47.17 89 999999999 41.34 50.35 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS, PERFORMED FOR OTHER THAN COLORECTAL NEOPLASM SCREENING" 82272_1 CDM 309 RC 82272 HCPCS outpatient 53 39.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 47.17 89 999999999 41.34 50.35 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS, PERFORMED FOR OTHER THAN COLORECTAL NEOPLASM SCREENING" 82272_1 CDM 309 RC 82272 HCPCS outpatient 53 39.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 47.7 90 999999999 41.34 50.35 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS, PERFORMED FOR OTHER THAN COLORECTAL NEOPLASM SCREENING" 82272_1 CDM 309 RC 82272 HCPCS outpatient 53 39.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50.35 95 999999999 41.34 50.35 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS, PERFORMED FOR OTHER THAN COLORECTAL NEOPLASM SCREENING" 82272_1 CDM 309 RC 82272 HCPCS outpatient 53 39.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50.35 95 999999999 41.34 50.35 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS, PERFORMED FOR OTHER THAN COLORECTAL NEOPLASM SCREENING" 82272_1 CDM 309 RC 82272 HCPCS outpatient 53 39.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 47.17 89 999999999 41.34 50.35 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS, PERFORMED FOR OTHER THAN COLORECTAL NEOPLASM SCREENING" 82272_1 CDM 309 RC 82272 HCPCS outpatient 53 39.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 46.64 88 999999999 41.34 50.35 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS, PERFORMED FOR OTHER THAN COLORECTAL NEOPLASM SCREENING" 82272_1 CDM 309 RC 82272 HCPCS outpatient 53 39.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 47.17 89 999999999 41.34 50.35 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS, PERFORMED FOR OTHER THAN COLORECTAL NEOPLASM SCREENING" 82272_3 CDM 309 RC 82272 HCPCS outpatient 53 39.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 47.7 90 999999999 41.34 50.35 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS, PERFORMED FOR OTHER THAN COLORECTAL NEOPLASM SCREENING" 82272_3 CDM 309 RC 82272 HCPCS outpatient 53 39.75 AETNA MCR ADV AETNA MCR ADV 41.34 78 999999999 41.34 50.35 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS, PERFORMED FOR OTHER THAN COLORECTAL NEOPLASM SCREENING" 82272_3 CDM 309 RC 82272 HCPCS outpatient 53 39.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 46.41 87.57 999999999 41.34 50.35 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS, PERFORMED FOR OTHER THAN COLORECTAL NEOPLASM SCREENING" 82272_3 CDM 309 RC 82272 HCPCS outpatient 53 39.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 45.09 85.07 999999999 41.34 50.35 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS, PERFORMED FOR OTHER THAN COLORECTAL NEOPLASM SCREENING" 82272_3 CDM 309 RC 82272 HCPCS outpatient 53 39.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 45.09 85.07 999999999 41.34 50.35 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS, PERFORMED FOR OTHER THAN COLORECTAL NEOPLASM SCREENING" 82272_3 CDM 309 RC 82272 HCPCS outpatient 53 39.75 MOLINA MCAID MOLINA MCAID 44.2 83.4 999999999 41.34 50.35 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS, PERFORMED FOR OTHER THAN COLORECTAL NEOPLASM SCREENING" 82272_3 CDM 309 RC 82272 HCPCS outpatient 53 39.75 MOLINA MCR ADV MOLINA MCR ADV 47.17 89 999999999 41.34 50.35 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS, PERFORMED FOR OTHER THAN COLORECTAL NEOPLASM SCREENING" 82272_3 CDM 309 RC 82272 HCPCS outpatient 53 39.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 47.17 89 999999999 41.34 50.35 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS, PERFORMED FOR OTHER THAN COLORECTAL NEOPLASM SCREENING" 82272_3 CDM 309 RC 82272 HCPCS outpatient 53 39.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 47.17 89 999999999 41.34 50.35 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS, PERFORMED FOR OTHER THAN COLORECTAL NEOPLASM SCREENING" 82272_3 CDM 309 RC 82272 HCPCS outpatient 53 39.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 47.7 90 999999999 41.34 50.35 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS, PERFORMED FOR OTHER THAN COLORECTAL NEOPLASM SCREENING" 82272_3 CDM 309 RC 82272 HCPCS outpatient 53 39.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50.35 95 999999999 41.34 50.35 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS, PERFORMED FOR OTHER THAN COLORECTAL NEOPLASM SCREENING" 82272_3 CDM 309 RC 82272 HCPCS outpatient 53 39.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50.35 95 999999999 41.34 50.35 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS, PERFORMED FOR OTHER THAN COLORECTAL NEOPLASM SCREENING" 82272_3 CDM 309 RC 82272 HCPCS outpatient 53 39.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 47.17 89 999999999 41.34 50.35 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS, PERFORMED FOR OTHER THAN COLORECTAL NEOPLASM SCREENING" 82272_3 CDM 309 RC 82272 HCPCS outpatient 53 39.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 46.64 88 999999999 41.34 50.35 percent of total billed charges "BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS, PERFORMED FOR OTHER THAN COLORECTAL NEOPLASM SCREENING" 82272_3 CDM 309 RC 82272 HCPCS outpatient 53 39.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 47.17 89 999999999 41.34 50.35 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 82274_1 CDM 301 RC 82274 HCPCS outpatient 48 36 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 43.2 90 999999999 37.44 45.6 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 82274_1 CDM 301 RC 82274 HCPCS outpatient 48 36 AETNA MCR ADV AETNA MCR ADV 37.44 78 999999999 37.44 45.6 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 82274_1 CDM 301 RC 82274 HCPCS outpatient 48 36 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 42.03 87.57 999999999 37.44 45.6 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 82274_1 CDM 301 RC 82274 HCPCS outpatient 48 36 COORDINATED CARE MCAID COORDINATED CARE MCAID 40.83 85.07 999999999 37.44 45.6 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 82274_1 CDM 301 RC 82274 HCPCS outpatient 48 36 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 40.83 85.07 999999999 37.44 45.6 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 82274_1 CDM 301 RC 82274 HCPCS outpatient 48 36 MOLINA MCAID MOLINA MCAID 40.03 83.4 999999999 37.44 45.6 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 82274_1 CDM 301 RC 82274 HCPCS outpatient 48 36 MOLINA MCR ADV MOLINA MCR ADV 42.72 89 999999999 37.44 45.6 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 82274_1 CDM 301 RC 82274 HCPCS outpatient 48 36 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 42.72 89 999999999 37.44 45.6 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 82274_1 CDM 301 RC 82274 HCPCS outpatient 48 36 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 42.72 89 999999999 37.44 45.6 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 82274_1 CDM 301 RC 82274 HCPCS outpatient 48 36 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 43.2 90 999999999 37.44 45.6 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 82274_1 CDM 301 RC 82274 HCPCS outpatient 48 36 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 45.6 95 999999999 37.44 45.6 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 82274_1 CDM 301 RC 82274 HCPCS outpatient 48 36 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 45.6 95 999999999 37.44 45.6 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 82274_1 CDM 301 RC 82274 HCPCS outpatient 48 36 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 42.72 89 999999999 37.44 45.6 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 82274_1 CDM 301 RC 82274 HCPCS outpatient 48 36 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 42.24 88 999999999 37.44 45.6 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 82274_1 CDM 301 RC 82274 HCPCS outpatient 48 36 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 42.72 89 999999999 37.44 45.6 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 82274_3 CDM 301 RC 82274 HCPCS outpatient 48 36 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 43.2 90 999999999 37.44 45.6 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 82274_3 CDM 301 RC 82274 HCPCS outpatient 48 36 AETNA MCR ADV AETNA MCR ADV 37.44 78 999999999 37.44 45.6 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 82274_3 CDM 301 RC 82274 HCPCS outpatient 48 36 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 42.03 87.57 999999999 37.44 45.6 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 82274_3 CDM 301 RC 82274 HCPCS outpatient 48 36 COORDINATED CARE MCAID COORDINATED CARE MCAID 40.83 85.07 999999999 37.44 45.6 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 82274_3 CDM 301 RC 82274 HCPCS outpatient 48 36 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 40.83 85.07 999999999 37.44 45.6 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 82274_3 CDM 301 RC 82274 HCPCS outpatient 48 36 MOLINA MCAID MOLINA MCAID 40.03 83.4 999999999 37.44 45.6 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 82274_3 CDM 301 RC 82274 HCPCS outpatient 48 36 MOLINA MCR ADV MOLINA MCR ADV 42.72 89 999999999 37.44 45.6 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 82274_3 CDM 301 RC 82274 HCPCS outpatient 48 36 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 42.72 89 999999999 37.44 45.6 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 82274_3 CDM 301 RC 82274 HCPCS outpatient 48 36 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 42.72 89 999999999 37.44 45.6 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 82274_3 CDM 301 RC 82274 HCPCS outpatient 48 36 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 43.2 90 999999999 37.44 45.6 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 82274_3 CDM 301 RC 82274 HCPCS outpatient 48 36 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 45.6 95 999999999 37.44 45.6 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 82274_3 CDM 301 RC 82274 HCPCS outpatient 48 36 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 45.6 95 999999999 37.44 45.6 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 82274_3 CDM 301 RC 82274 HCPCS outpatient 48 36 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 42.72 89 999999999 37.44 45.6 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 82274_3 CDM 301 RC 82274 HCPCS outpatient 48 36 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 42.24 88 999999999 37.44 45.6 percent of total billed charges "BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS" 82274_3 CDM 301 RC 82274 HCPCS outpatient 48 36 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 42.72 89 999999999 37.44 45.6 percent of total billed charges "GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT STRIP)" 82947_3 CDM 300 RC 82947 HCPCS outpatient 11.79 8.84 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 10.61 90 999999999 9.2 11.2 percent of total billed charges "GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT STRIP)" 82947_3 CDM 300 RC 82947 HCPCS outpatient 11.79 8.84 AETNA MCR ADV AETNA MCR ADV 9.2 78 999999999 9.2 11.2 percent of total billed charges "GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT STRIP)" 82947_3 CDM 300 RC 82947 HCPCS outpatient 11.79 8.84 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 10.32 87.57 999999999 9.2 11.2 percent of total billed charges "GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT STRIP)" 82947_3 CDM 300 RC 82947 HCPCS outpatient 11.79 8.84 COORDINATED CARE MCAID COORDINATED CARE MCAID 10.03 85.07 999999999 9.2 11.2 percent of total billed charges "GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT STRIP)" 82947_3 CDM 300 RC 82947 HCPCS outpatient 11.79 8.84 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 10.03 85.07 999999999 9.2 11.2 percent of total billed charges "GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT STRIP)" 82947_3 CDM 300 RC 82947 HCPCS outpatient 11.79 8.84 MOLINA MCAID MOLINA MCAID 9.83 83.4 999999999 9.2 11.2 percent of total billed charges "GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT STRIP)" 82947_3 CDM 300 RC 82947 HCPCS outpatient 11.79 8.84 MOLINA MCR ADV MOLINA MCR ADV 10.49 89 999999999 9.2 11.2 percent of total billed charges "GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT STRIP)" 82947_3 CDM 300 RC 82947 HCPCS outpatient 11.79 8.84 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 10.49 89 999999999 9.2 11.2 percent of total billed charges "GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT STRIP)" 82947_3 CDM 300 RC 82947 HCPCS outpatient 11.79 8.84 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 10.49 89 999999999 9.2 11.2 percent of total billed charges "GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT STRIP)" 82947_3 CDM 300 RC 82947 HCPCS outpatient 11.79 8.84 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 10.61 90 999999999 9.2 11.2 percent of total billed charges "GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT STRIP)" 82947_3 CDM 300 RC 82947 HCPCS outpatient 11.79 8.84 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 11.2 95 999999999 9.2 11.2 percent of total billed charges "GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT STRIP)" 82947_3 CDM 300 RC 82947 HCPCS outpatient 11.79 8.84 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 11.2 95 999999999 9.2 11.2 percent of total billed charges "GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT STRIP)" 82947_3 CDM 300 RC 82947 HCPCS outpatient 11.79 8.84 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 10.49 89 999999999 9.2 11.2 percent of total billed charges "GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT STRIP)" 82947_3 CDM 300 RC 82947 HCPCS outpatient 11.79 8.84 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 10.38 88 999999999 9.2 11.2 percent of total billed charges "GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT STRIP)" 82947_3 CDM 300 RC 82947 HCPCS outpatient 11.79 8.84 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 10.49 89 999999999 9.2 11.2 percent of total billed charges "GLUCOSE; BLOOD, REAGENT STRIP" 82948_1 CDM 301 RC 82948 HCPCS outpatient 35 26.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 31.5 90 999999999 27.3 33.25 percent of total billed charges "GLUCOSE; BLOOD, REAGENT STRIP" 82948_1 CDM 301 RC 82948 HCPCS outpatient 35 26.25 AETNA MCR ADV AETNA MCR ADV 27.3 78 999999999 27.3 33.25 percent of total billed charges "GLUCOSE; BLOOD, REAGENT STRIP" 82948_1 CDM 301 RC 82948 HCPCS outpatient 35 26.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 30.65 87.57 999999999 27.3 33.25 percent of total billed charges "GLUCOSE; BLOOD, REAGENT STRIP" 82948_1 CDM 301 RC 82948 HCPCS outpatient 35 26.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 29.77 85.07 999999999 27.3 33.25 percent of total billed charges "GLUCOSE; BLOOD, REAGENT STRIP" 82948_1 CDM 301 RC 82948 HCPCS outpatient 35 26.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 29.77 85.07 999999999 27.3 33.25 percent of total billed charges "GLUCOSE; BLOOD, REAGENT STRIP" 82948_1 CDM 301 RC 82948 HCPCS outpatient 35 26.25 MOLINA MCAID MOLINA MCAID 29.19 83.4 999999999 27.3 33.25 percent of total billed charges "GLUCOSE; BLOOD, REAGENT STRIP" 82948_1 CDM 301 RC 82948 HCPCS outpatient 35 26.25 MOLINA MCR ADV MOLINA MCR ADV 31.15 89 999999999 27.3 33.25 percent of total billed charges "GLUCOSE; BLOOD, REAGENT STRIP" 82948_1 CDM 301 RC 82948 HCPCS outpatient 35 26.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 31.15 89 999999999 27.3 33.25 percent of total billed charges "GLUCOSE; BLOOD, REAGENT STRIP" 82948_1 CDM 301 RC 82948 HCPCS outpatient 35 26.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 31.15 89 999999999 27.3 33.25 percent of total billed charges "GLUCOSE; BLOOD, REAGENT STRIP" 82948_1 CDM 301 RC 82948 HCPCS outpatient 35 26.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 31.5 90 999999999 27.3 33.25 percent of total billed charges "GLUCOSE; BLOOD, REAGENT STRIP" 82948_1 CDM 301 RC 82948 HCPCS outpatient 35 26.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 33.25 95 999999999 27.3 33.25 percent of total billed charges "GLUCOSE; BLOOD, REAGENT STRIP" 82948_1 CDM 301 RC 82948 HCPCS outpatient 35 26.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 33.25 95 999999999 27.3 33.25 percent of total billed charges "GLUCOSE; BLOOD, REAGENT STRIP" 82948_1 CDM 301 RC 82948 HCPCS outpatient 35 26.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 31.15 89 999999999 27.3 33.25 percent of total billed charges "GLUCOSE; BLOOD, REAGENT STRIP" 82948_1 CDM 301 RC 82948 HCPCS outpatient 35 26.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 30.8 88 999999999 27.3 33.25 percent of total billed charges "GLUCOSE; BLOOD, REAGENT STRIP" 82948_1 CDM 301 RC 82948 HCPCS outpatient 35 26.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 31.15 89 999999999 27.3 33.25 percent of total billed charges "GLUCOSE; BLOOD, REAGENT STRIP" 82948_3 CDM 301 RC 82948 HCPCS outpatient 15.12 11.34 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 13.61 90 999999999 11.79 14.36 percent of total billed charges "GLUCOSE; BLOOD, REAGENT STRIP" 82948_3 CDM 301 RC 82948 HCPCS outpatient 15.12 11.34 AETNA MCR ADV AETNA MCR ADV 11.79 78 999999999 11.79 14.36 percent of total billed charges "GLUCOSE; BLOOD, REAGENT STRIP" 82948_3 CDM 301 RC 82948 HCPCS outpatient 15.12 11.34 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 13.24 87.57 999999999 11.79 14.36 percent of total billed charges "GLUCOSE; BLOOD, REAGENT STRIP" 82948_3 CDM 301 RC 82948 HCPCS outpatient 15.12 11.34 COORDINATED CARE MCAID COORDINATED CARE MCAID 12.86 85.07 999999999 11.79 14.36 percent of total billed charges "GLUCOSE; BLOOD, REAGENT STRIP" 82948_3 CDM 301 RC 82948 HCPCS outpatient 15.12 11.34 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 12.86 85.07 999999999 11.79 14.36 percent of total billed charges "GLUCOSE; BLOOD, REAGENT STRIP" 82948_3 CDM 301 RC 82948 HCPCS outpatient 15.12 11.34 MOLINA MCAID MOLINA MCAID 12.61 83.4 999999999 11.79 14.36 percent of total billed charges "GLUCOSE; BLOOD, REAGENT STRIP" 82948_3 CDM 301 RC 82948 HCPCS outpatient 15.12 11.34 MOLINA MCR ADV MOLINA MCR ADV 13.46 89 999999999 11.79 14.36 percent of total billed charges "GLUCOSE; BLOOD, REAGENT STRIP" 82948_3 CDM 301 RC 82948 HCPCS outpatient 15.12 11.34 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 13.46 89 999999999 11.79 14.36 percent of total billed charges "GLUCOSE; BLOOD, REAGENT STRIP" 82948_3 CDM 301 RC 82948 HCPCS outpatient 15.12 11.34 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 13.46 89 999999999 11.79 14.36 percent of total billed charges "GLUCOSE; BLOOD, REAGENT STRIP" 82948_3 CDM 301 RC 82948 HCPCS outpatient 15.12 11.34 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 13.61 90 999999999 11.79 14.36 percent of total billed charges "GLUCOSE; BLOOD, REAGENT STRIP" 82948_3 CDM 301 RC 82948 HCPCS outpatient 15.12 11.34 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 14.36 95 999999999 11.79 14.36 percent of total billed charges "GLUCOSE; BLOOD, REAGENT STRIP" 82948_3 CDM 301 RC 82948 HCPCS outpatient 15.12 11.34 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 14.36 95 999999999 11.79 14.36 percent of total billed charges "GLUCOSE; BLOOD, REAGENT STRIP" 82948_3 CDM 301 RC 82948 HCPCS outpatient 15.12 11.34 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 13.46 89 999999999 11.79 14.36 percent of total billed charges "GLUCOSE; BLOOD, REAGENT STRIP" 82948_3 CDM 301 RC 82948 HCPCS outpatient 15.12 11.34 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 13.31 88 999999999 11.79 14.36 percent of total billed charges "GLUCOSE; BLOOD, REAGENT STRIP" 82948_3 CDM 301 RC 82948 HCPCS outpatient 15.12 11.34 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 13.46 89 999999999 11.79 14.36 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; LDL CHOLESTEROL" 83721_1 CDM 301 RC 83721 HCPCS outpatient 73 54.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 65.7 90 999999999 56.94 69.35 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; LDL CHOLESTEROL" 83721_1 CDM 301 RC 83721 HCPCS outpatient 73 54.75 AETNA MCR ADV AETNA MCR ADV 56.94 78 999999999 56.94 69.35 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; LDL CHOLESTEROL" 83721_1 CDM 301 RC 83721 HCPCS outpatient 73 54.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 63.93 87.57 999999999 56.94 69.35 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; LDL CHOLESTEROL" 83721_1 CDM 301 RC 83721 HCPCS outpatient 73 54.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 62.1 85.07 999999999 56.94 69.35 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; LDL CHOLESTEROL" 83721_1 CDM 301 RC 83721 HCPCS outpatient 73 54.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 62.1 85.07 999999999 56.94 69.35 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; LDL CHOLESTEROL" 83721_1 CDM 301 RC 83721 HCPCS outpatient 73 54.75 MOLINA MCAID MOLINA MCAID 60.88 83.4 999999999 56.94 69.35 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; LDL CHOLESTEROL" 83721_1 CDM 301 RC 83721 HCPCS outpatient 73 54.75 MOLINA MCR ADV MOLINA MCR ADV 64.97 89 999999999 56.94 69.35 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; LDL CHOLESTEROL" 83721_1 CDM 301 RC 83721 HCPCS outpatient 73 54.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 64.97 89 999999999 56.94 69.35 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; LDL CHOLESTEROL" 83721_1 CDM 301 RC 83721 HCPCS outpatient 73 54.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 64.97 89 999999999 56.94 69.35 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; LDL CHOLESTEROL" 83721_1 CDM 301 RC 83721 HCPCS outpatient 73 54.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 65.7 90 999999999 56.94 69.35 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; LDL CHOLESTEROL" 83721_1 CDM 301 RC 83721 HCPCS outpatient 73 54.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 69.35 95 999999999 56.94 69.35 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; LDL CHOLESTEROL" 83721_1 CDM 301 RC 83721 HCPCS outpatient 73 54.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 69.35 95 999999999 56.94 69.35 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; LDL CHOLESTEROL" 83721_1 CDM 301 RC 83721 HCPCS outpatient 73 54.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 64.97 89 999999999 56.94 69.35 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; LDL CHOLESTEROL" 83721_1 CDM 301 RC 83721 HCPCS outpatient 73 54.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 64.24 88 999999999 56.94 69.35 percent of total billed charges "LIPOPROTEIN, DIRECT MEASUREMENT; LDL CHOLESTEROL" 83721_1 CDM 301 RC 83721 HCPCS outpatient 73 54.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 64.97 89 999999999 56.94 69.35 percent of total billed charges "PH; BODY FLUID, NOT OTHERWISE SPECIFIED" 83986_1 CDM 300 RC 83986 HCPCS outpatient 12 9 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 10.8 90 999999999 9.36 11.4 percent of total billed charges "PH; BODY FLUID, NOT OTHERWISE SPECIFIED" 83986_1 CDM 300 RC 83986 HCPCS outpatient 12 9 AETNA MCR ADV AETNA MCR ADV 9.36 78 999999999 9.36 11.4 percent of total billed charges "PH; BODY FLUID, NOT OTHERWISE SPECIFIED" 83986_1 CDM 300 RC 83986 HCPCS outpatient 12 9 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 10.51 87.57 999999999 9.36 11.4 percent of total billed charges "PH; BODY FLUID, NOT OTHERWISE SPECIFIED" 83986_1 CDM 300 RC 83986 HCPCS outpatient 12 9 COORDINATED CARE MCAID COORDINATED CARE MCAID 10.21 85.07 999999999 9.36 11.4 percent of total billed charges "PH; BODY FLUID, NOT OTHERWISE SPECIFIED" 83986_1 CDM 300 RC 83986 HCPCS outpatient 12 9 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 10.21 85.07 999999999 9.36 11.4 percent of total billed charges "PH; BODY FLUID, NOT OTHERWISE SPECIFIED" 83986_1 CDM 300 RC 83986 HCPCS outpatient 12 9 MOLINA MCAID MOLINA MCAID 10.01 83.4 999999999 9.36 11.4 percent of total billed charges "PH; BODY FLUID, NOT OTHERWISE SPECIFIED" 83986_1 CDM 300 RC 83986 HCPCS outpatient 12 9 MOLINA MCR ADV MOLINA MCR ADV 10.68 89 999999999 9.36 11.4 percent of total billed charges "PH; BODY FLUID, NOT OTHERWISE SPECIFIED" 83986_1 CDM 300 RC 83986 HCPCS outpatient 12 9 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 10.68 89 999999999 9.36 11.4 percent of total billed charges "PH; BODY FLUID, NOT OTHERWISE SPECIFIED" 83986_1 CDM 300 RC 83986 HCPCS outpatient 12 9 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 10.68 89 999999999 9.36 11.4 percent of total billed charges "PH; BODY FLUID, NOT OTHERWISE SPECIFIED" 83986_1 CDM 300 RC 83986 HCPCS outpatient 12 9 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 10.8 90 999999999 9.36 11.4 percent of total billed charges "PH; BODY FLUID, NOT OTHERWISE SPECIFIED" 83986_1 CDM 300 RC 83986 HCPCS outpatient 12 9 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 11.4 95 999999999 9.36 11.4 percent of total billed charges "PH; BODY FLUID, NOT OTHERWISE SPECIFIED" 83986_1 CDM 300 RC 83986 HCPCS outpatient 12 9 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 11.4 95 999999999 9.36 11.4 percent of total billed charges "PH; BODY FLUID, NOT OTHERWISE SPECIFIED" 83986_1 CDM 300 RC 83986 HCPCS outpatient 12 9 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 10.68 89 999999999 9.36 11.4 percent of total billed charges "PH; BODY FLUID, NOT OTHERWISE SPECIFIED" 83986_1 CDM 300 RC 83986 HCPCS outpatient 12 9 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 10.56 88 999999999 9.36 11.4 percent of total billed charges "PH; BODY FLUID, NOT OTHERWISE SPECIFIED" 83986_1 CDM 300 RC 83986 HCPCS outpatient 12 9 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 10.68 89 999999999 9.36 11.4 percent of total billed charges "PH; BODY FLUID, NOT OTHERWISE SPECIFIED" 83986_3 CDM 300 RC 83986 HCPCS outpatient 12 9 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 10.8 90 999999999 9.36 11.4 percent of total billed charges "PH; BODY FLUID, NOT OTHERWISE SPECIFIED" 83986_3 CDM 300 RC 83986 HCPCS outpatient 12 9 AETNA MCR ADV AETNA MCR ADV 9.36 78 999999999 9.36 11.4 percent of total billed charges "PH; BODY FLUID, NOT OTHERWISE SPECIFIED" 83986_3 CDM 300 RC 83986 HCPCS outpatient 12 9 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 10.51 87.57 999999999 9.36 11.4 percent of total billed charges "PH; BODY FLUID, NOT OTHERWISE SPECIFIED" 83986_3 CDM 300 RC 83986 HCPCS outpatient 12 9 COORDINATED CARE MCAID COORDINATED CARE MCAID 10.21 85.07 999999999 9.36 11.4 percent of total billed charges "PH; BODY FLUID, NOT OTHERWISE SPECIFIED" 83986_3 CDM 300 RC 83986 HCPCS outpatient 12 9 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 10.21 85.07 999999999 9.36 11.4 percent of total billed charges "PH; BODY FLUID, NOT OTHERWISE SPECIFIED" 83986_3 CDM 300 RC 83986 HCPCS outpatient 12 9 MOLINA MCAID MOLINA MCAID 10.01 83.4 999999999 9.36 11.4 percent of total billed charges "PH; BODY FLUID, NOT OTHERWISE SPECIFIED" 83986_3 CDM 300 RC 83986 HCPCS outpatient 12 9 MOLINA MCR ADV MOLINA MCR ADV 10.68 89 999999999 9.36 11.4 percent of total billed charges "PH; BODY FLUID, NOT OTHERWISE SPECIFIED" 83986_3 CDM 300 RC 83986 HCPCS outpatient 12 9 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 10.68 89 999999999 9.36 11.4 percent of total billed charges "PH; BODY FLUID, NOT OTHERWISE SPECIFIED" 83986_3 CDM 300 RC 83986 HCPCS outpatient 12 9 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 10.68 89 999999999 9.36 11.4 percent of total billed charges "PH; BODY FLUID, NOT OTHERWISE SPECIFIED" 83986_3 CDM 300 RC 83986 HCPCS outpatient 12 9 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 10.8 90 999999999 9.36 11.4 percent of total billed charges "PH; BODY FLUID, NOT OTHERWISE SPECIFIED" 83986_3 CDM 300 RC 83986 HCPCS outpatient 12 9 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 11.4 95 999999999 9.36 11.4 percent of total billed charges "PH; BODY FLUID, NOT OTHERWISE SPECIFIED" 83986_3 CDM 300 RC 83986 HCPCS outpatient 12 9 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 11.4 95 999999999 9.36 11.4 percent of total billed charges "PH; BODY FLUID, NOT OTHERWISE SPECIFIED" 83986_3 CDM 300 RC 83986 HCPCS outpatient 12 9 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 10.68 89 999999999 9.36 11.4 percent of total billed charges "PH; BODY FLUID, NOT OTHERWISE SPECIFIED" 83986_3 CDM 300 RC 83986 HCPCS outpatient 12 9 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 10.56 88 999999999 9.36 11.4 percent of total billed charges "PH; BODY FLUID, NOT OTHERWISE SPECIFIED" 83986_3 CDM 300 RC 83986 HCPCS outpatient 12 9 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 10.68 89 999999999 9.36 11.4 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUANTITATIVE" 84702F_3 CDM 301 RC 84702 HCPCS outpatient 45.15 33.86 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 40.64 90 999999999 35.22 42.89 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUANTITATIVE" 84702F_3 CDM 301 RC 84702 HCPCS outpatient 45.15 33.86 AETNA MCR ADV AETNA MCR ADV 35.22 78 999999999 35.22 42.89 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUANTITATIVE" 84702F_3 CDM 301 RC 84702 HCPCS outpatient 45.15 33.86 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 39.54 87.57 999999999 35.22 42.89 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUANTITATIVE" 84702F_3 CDM 301 RC 84702 HCPCS outpatient 45.15 33.86 COORDINATED CARE MCAID COORDINATED CARE MCAID 38.41 85.07 999999999 35.22 42.89 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUANTITATIVE" 84702F_3 CDM 301 RC 84702 HCPCS outpatient 45.15 33.86 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 38.41 85.07 999999999 35.22 42.89 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUANTITATIVE" 84702F_3 CDM 301 RC 84702 HCPCS outpatient 45.15 33.86 MOLINA MCAID MOLINA MCAID 37.66 83.4 999999999 35.22 42.89 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUANTITATIVE" 84702F_3 CDM 301 RC 84702 HCPCS outpatient 45.15 33.86 MOLINA MCR ADV MOLINA MCR ADV 40.18 89 999999999 35.22 42.89 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUANTITATIVE" 84702F_3 CDM 301 RC 84702 HCPCS outpatient 45.15 33.86 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 40.18 89 999999999 35.22 42.89 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUANTITATIVE" 84702F_3 CDM 301 RC 84702 HCPCS outpatient 45.15 33.86 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 40.18 89 999999999 35.22 42.89 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUANTITATIVE" 84702F_3 CDM 301 RC 84702 HCPCS outpatient 45.15 33.86 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 40.64 90 999999999 35.22 42.89 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUANTITATIVE" 84702F_3 CDM 301 RC 84702 HCPCS outpatient 45.15 33.86 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 42.89 95 999999999 35.22 42.89 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUANTITATIVE" 84702F_3 CDM 301 RC 84702 HCPCS outpatient 45.15 33.86 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 42.89 95 999999999 35.22 42.89 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUANTITATIVE" 84702F_3 CDM 301 RC 84702 HCPCS outpatient 45.15 33.86 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 40.18 89 999999999 35.22 42.89 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUANTITATIVE" 84702F_3 CDM 301 RC 84702 HCPCS outpatient 45.15 33.86 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 39.73 88 999999999 35.22 42.89 percent of total billed charges "GONADOTROPIN, CHORIONIC (HCG); QUANTITATIVE" 84702F_3 CDM 301 RC 84702 HCPCS outpatient 45.15 33.86 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 40.18 89 999999999 35.22 42.89 percent of total billed charges BLOOD COUNT; HEMATOCRIT (HCT) 85014A_3 CDM 305 RC 85014 HCPCS outpatient 7.11 5.33 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 6.4 90 999999999 5.55 6.75 percent of total billed charges BLOOD COUNT; HEMATOCRIT (HCT) 85014A_3 CDM 305 RC 85014 HCPCS outpatient 7.11 5.33 AETNA MCR ADV AETNA MCR ADV 5.55 78 999999999 5.55 6.75 percent of total billed charges BLOOD COUNT; HEMATOCRIT (HCT) 85014A_3 CDM 305 RC 85014 HCPCS outpatient 7.11 5.33 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 6.23 87.57 999999999 5.55 6.75 percent of total billed charges BLOOD COUNT; HEMATOCRIT (HCT) 85014A_3 CDM 305 RC 85014 HCPCS outpatient 7.11 5.33 COORDINATED CARE MCAID COORDINATED CARE MCAID 6.05 85.07 999999999 5.55 6.75 percent of total billed charges BLOOD COUNT; HEMATOCRIT (HCT) 85014A_3 CDM 305 RC 85014 HCPCS outpatient 7.11 5.33 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 6.05 85.07 999999999 5.55 6.75 percent of total billed charges BLOOD COUNT; HEMATOCRIT (HCT) 85014A_3 CDM 305 RC 85014 HCPCS outpatient 7.11 5.33 MOLINA MCAID MOLINA MCAID 5.93 83.4 999999999 5.55 6.75 percent of total billed charges BLOOD COUNT; HEMATOCRIT (HCT) 85014A_3 CDM 305 RC 85014 HCPCS outpatient 7.11 5.33 MOLINA MCR ADV MOLINA MCR ADV 6.33 89 999999999 5.55 6.75 percent of total billed charges BLOOD COUNT; HEMATOCRIT (HCT) 85014A_3 CDM 305 RC 85014 HCPCS outpatient 7.11 5.33 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 6.33 89 999999999 5.55 6.75 percent of total billed charges BLOOD COUNT; HEMATOCRIT (HCT) 85014A_3 CDM 305 RC 85014 HCPCS outpatient 7.11 5.33 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 6.33 89 999999999 5.55 6.75 percent of total billed charges BLOOD COUNT; HEMATOCRIT (HCT) 85014A_3 CDM 305 RC 85014 HCPCS outpatient 7.11 5.33 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 6.4 90 999999999 5.55 6.75 percent of total billed charges BLOOD COUNT; HEMATOCRIT (HCT) 85014A_3 CDM 305 RC 85014 HCPCS outpatient 7.11 5.33 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 6.75 95 999999999 5.55 6.75 percent of total billed charges BLOOD COUNT; HEMATOCRIT (HCT) 85014A_3 CDM 305 RC 85014 HCPCS outpatient 7.11 5.33 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 6.75 95 999999999 5.55 6.75 percent of total billed charges BLOOD COUNT; HEMATOCRIT (HCT) 85014A_3 CDM 305 RC 85014 HCPCS outpatient 7.11 5.33 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 6.33 89 999999999 5.55 6.75 percent of total billed charges BLOOD COUNT; HEMATOCRIT (HCT) 85014A_3 CDM 305 RC 85014 HCPCS outpatient 7.11 5.33 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 6.26 88 999999999 5.55 6.75 percent of total billed charges BLOOD COUNT; HEMATOCRIT (HCT) 85014A_3 CDM 305 RC 85014 HCPCS outpatient 7.11 5.33 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 6.33 89 999999999 5.55 6.75 percent of total billed charges BLOOD COUNT; HEMOGLOBIN (HGB) 85018_3 CDM 300 RC 85018 HCPCS outpatient 7.11 5.33 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 6.4 90 999999999 5.55 6.75 percent of total billed charges BLOOD COUNT; HEMOGLOBIN (HGB) 85018_3 CDM 300 RC 85018 HCPCS outpatient 7.11 5.33 AETNA MCR ADV AETNA MCR ADV 5.55 78 999999999 5.55 6.75 percent of total billed charges BLOOD COUNT; HEMOGLOBIN (HGB) 85018_3 CDM 300 RC 85018 HCPCS outpatient 7.11 5.33 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 6.23 87.57 999999999 5.55 6.75 percent of total billed charges BLOOD COUNT; HEMOGLOBIN (HGB) 85018_3 CDM 300 RC 85018 HCPCS outpatient 7.11 5.33 COORDINATED CARE MCAID COORDINATED CARE MCAID 6.05 85.07 999999999 5.55 6.75 percent of total billed charges BLOOD COUNT; HEMOGLOBIN (HGB) 85018_3 CDM 300 RC 85018 HCPCS outpatient 7.11 5.33 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 6.05 85.07 999999999 5.55 6.75 percent of total billed charges BLOOD COUNT; HEMOGLOBIN (HGB) 85018_3 CDM 300 RC 85018 HCPCS outpatient 7.11 5.33 MOLINA MCAID MOLINA MCAID 5.93 83.4 999999999 5.55 6.75 percent of total billed charges BLOOD COUNT; HEMOGLOBIN (HGB) 85018_3 CDM 300 RC 85018 HCPCS outpatient 7.11 5.33 MOLINA MCR ADV MOLINA MCR ADV 6.33 89 999999999 5.55 6.75 percent of total billed charges BLOOD COUNT; HEMOGLOBIN (HGB) 85018_3 CDM 300 RC 85018 HCPCS outpatient 7.11 5.33 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 6.33 89 999999999 5.55 6.75 percent of total billed charges BLOOD COUNT; HEMOGLOBIN (HGB) 85018_3 CDM 300 RC 85018 HCPCS outpatient 7.11 5.33 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 6.33 89 999999999 5.55 6.75 percent of total billed charges BLOOD COUNT; HEMOGLOBIN (HGB) 85018_3 CDM 300 RC 85018 HCPCS outpatient 7.11 5.33 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 6.4 90 999999999 5.55 6.75 percent of total billed charges BLOOD COUNT; HEMOGLOBIN (HGB) 85018_3 CDM 300 RC 85018 HCPCS outpatient 7.11 5.33 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 6.75 95 999999999 5.55 6.75 percent of total billed charges BLOOD COUNT; HEMOGLOBIN (HGB) 85018_3 CDM 300 RC 85018 HCPCS outpatient 7.11 5.33 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 6.75 95 999999999 5.55 6.75 percent of total billed charges BLOOD COUNT; HEMOGLOBIN (HGB) 85018_3 CDM 300 RC 85018 HCPCS outpatient 7.11 5.33 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 6.33 89 999999999 5.55 6.75 percent of total billed charges BLOOD COUNT; HEMOGLOBIN (HGB) 85018_3 CDM 300 RC 85018 HCPCS outpatient 7.11 5.33 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 6.26 88 999999999 5.55 6.75 percent of total billed charges BLOOD COUNT; HEMOGLOBIN (HGB) 85018_3 CDM 300 RC 85018 HCPCS outpatient 7.11 5.33 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 6.33 89 999999999 5.55 6.75 percent of total billed charges PROTHROMBIN TIME 85610_1 CDM 305 RC 85610 HCPCS outpatient 56 42 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50.4 90 999999999 43.68 53.2 percent of total billed charges PROTHROMBIN TIME 85610_1 CDM 305 RC 85610 HCPCS outpatient 56 42 AETNA MCR ADV AETNA MCR ADV 43.68 78 999999999 43.68 53.2 percent of total billed charges PROTHROMBIN TIME 85610_1 CDM 305 RC 85610 HCPCS outpatient 56 42 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 49.04 87.57 999999999 43.68 53.2 percent of total billed charges PROTHROMBIN TIME 85610_1 CDM 305 RC 85610 HCPCS outpatient 56 42 COORDINATED CARE MCAID COORDINATED CARE MCAID 47.64 85.07 999999999 43.68 53.2 percent of total billed charges PROTHROMBIN TIME 85610_1 CDM 305 RC 85610 HCPCS outpatient 56 42 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 47.64 85.07 999999999 43.68 53.2 percent of total billed charges PROTHROMBIN TIME 85610_1 CDM 305 RC 85610 HCPCS outpatient 56 42 MOLINA MCAID MOLINA MCAID 46.7 83.4 999999999 43.68 53.2 percent of total billed charges PROTHROMBIN TIME 85610_1 CDM 305 RC 85610 HCPCS outpatient 56 42 MOLINA MCR ADV MOLINA MCR ADV 49.84 89 999999999 43.68 53.2 percent of total billed charges PROTHROMBIN TIME 85610_1 CDM 305 RC 85610 HCPCS outpatient 56 42 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 49.84 89 999999999 43.68 53.2 percent of total billed charges PROTHROMBIN TIME 85610_1 CDM 305 RC 85610 HCPCS outpatient 56 42 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 49.84 89 999999999 43.68 53.2 percent of total billed charges PROTHROMBIN TIME 85610_1 CDM 305 RC 85610 HCPCS outpatient 56 42 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50.4 90 999999999 43.68 53.2 percent of total billed charges PROTHROMBIN TIME 85610_1 CDM 305 RC 85610 HCPCS outpatient 56 42 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 53.2 95 999999999 43.68 53.2 percent of total billed charges PROTHROMBIN TIME 85610_1 CDM 305 RC 85610 HCPCS outpatient 56 42 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 53.2 95 999999999 43.68 53.2 percent of total billed charges PROTHROMBIN TIME 85610_1 CDM 305 RC 85610 HCPCS outpatient 56 42 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 49.84 89 999999999 43.68 53.2 percent of total billed charges PROTHROMBIN TIME 85610_1 CDM 305 RC 85610 HCPCS outpatient 56 42 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 49.28 88 999999999 43.68 53.2 percent of total billed charges PROTHROMBIN TIME 85610_1 CDM 305 RC 85610 HCPCS outpatient 56 42 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 49.84 89 999999999 43.68 53.2 percent of total billed charges "SKIN TEST; TUBERCULOSIS, INTRADERMAL" 86580_1 CDM 302 RC 86580 HCPCS outpatient 25 18.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 22.5 90 999999999 19.5 23.75 percent of total billed charges "SKIN TEST; TUBERCULOSIS, INTRADERMAL" 86580_1 CDM 302 RC 86580 HCPCS outpatient 25 18.75 AETNA MCR ADV AETNA MCR ADV 19.5 78 999999999 19.5 23.75 percent of total billed charges "SKIN TEST; TUBERCULOSIS, INTRADERMAL" 86580_1 CDM 302 RC 86580 HCPCS outpatient 25 18.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 21.89 87.57 999999999 19.5 23.75 percent of total billed charges "SKIN TEST; TUBERCULOSIS, INTRADERMAL" 86580_1 CDM 302 RC 86580 HCPCS outpatient 25 18.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 21.27 85.07 999999999 19.5 23.75 percent of total billed charges "SKIN TEST; TUBERCULOSIS, INTRADERMAL" 86580_1 CDM 302 RC 86580 HCPCS outpatient 25 18.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 21.27 85.07 999999999 19.5 23.75 percent of total billed charges "SKIN TEST; TUBERCULOSIS, INTRADERMAL" 86580_1 CDM 302 RC 86580 HCPCS outpatient 25 18.75 MOLINA MCAID MOLINA MCAID 20.85 83.4 999999999 19.5 23.75 percent of total billed charges "SKIN TEST; TUBERCULOSIS, INTRADERMAL" 86580_1 CDM 302 RC 86580 HCPCS outpatient 25 18.75 MOLINA MCR ADV MOLINA MCR ADV 22.25 89 999999999 19.5 23.75 percent of total billed charges "SKIN TEST; TUBERCULOSIS, INTRADERMAL" 86580_1 CDM 302 RC 86580 HCPCS outpatient 25 18.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 22.25 89 999999999 19.5 23.75 percent of total billed charges "SKIN TEST; TUBERCULOSIS, INTRADERMAL" 86580_1 CDM 302 RC 86580 HCPCS outpatient 25 18.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 22.25 89 999999999 19.5 23.75 percent of total billed charges "SKIN TEST; TUBERCULOSIS, INTRADERMAL" 86580_1 CDM 302 RC 86580 HCPCS outpatient 25 18.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 22.5 90 999999999 19.5 23.75 percent of total billed charges "SKIN TEST; TUBERCULOSIS, INTRADERMAL" 86580_1 CDM 302 RC 86580 HCPCS outpatient 25 18.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 23.75 95 999999999 19.5 23.75 percent of total billed charges "SKIN TEST; TUBERCULOSIS, INTRADERMAL" 86580_1 CDM 302 RC 86580 HCPCS outpatient 25 18.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 23.75 95 999999999 19.5 23.75 percent of total billed charges "SKIN TEST; TUBERCULOSIS, INTRADERMAL" 86580_1 CDM 302 RC 86580 HCPCS outpatient 25 18.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 22.25 89 999999999 19.5 23.75 percent of total billed charges "SKIN TEST; TUBERCULOSIS, INTRADERMAL" 86580_1 CDM 302 RC 86580 HCPCS outpatient 25 18.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 22 88 999999999 19.5 23.75 percent of total billed charges "SKIN TEST; TUBERCULOSIS, INTRADERMAL" 86580_1 CDM 302 RC 86580 HCPCS outpatient 25 18.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 22.25 89 999999999 19.5 23.75 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); RESPIRATORY SYNCYTIAL VIRUS, AMPLIFIED PROBE TECHNIQUE" 87634_1 CDM 306 RC 87634 HCPCS outpatient 135 101.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 121.5 90 999999999 105.3 128.25 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); RESPIRATORY SYNCYTIAL VIRUS, AMPLIFIED PROBE TECHNIQUE" 87634_1 CDM 306 RC 87634 HCPCS outpatient 135 101.25 AETNA MCR ADV AETNA MCR ADV 105.3 78 999999999 105.3 128.25 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); RESPIRATORY SYNCYTIAL VIRUS, AMPLIFIED PROBE TECHNIQUE" 87634_1 CDM 306 RC 87634 HCPCS outpatient 135 101.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 118.22 87.57 999999999 105.3 128.25 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); RESPIRATORY SYNCYTIAL VIRUS, AMPLIFIED PROBE TECHNIQUE" 87634_1 CDM 306 RC 87634 HCPCS outpatient 135 101.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 114.84 85.07 999999999 105.3 128.25 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); RESPIRATORY SYNCYTIAL VIRUS, AMPLIFIED PROBE TECHNIQUE" 87634_1 CDM 306 RC 87634 HCPCS outpatient 135 101.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 114.84 85.07 999999999 105.3 128.25 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); RESPIRATORY SYNCYTIAL VIRUS, AMPLIFIED PROBE TECHNIQUE" 87634_1 CDM 306 RC 87634 HCPCS outpatient 135 101.25 MOLINA MCAID MOLINA MCAID 112.59 83.4 999999999 105.3 128.25 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); RESPIRATORY SYNCYTIAL VIRUS, AMPLIFIED PROBE TECHNIQUE" 87634_1 CDM 306 RC 87634 HCPCS outpatient 135 101.25 MOLINA MCR ADV MOLINA MCR ADV 120.15 89 999999999 105.3 128.25 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); RESPIRATORY SYNCYTIAL VIRUS, AMPLIFIED PROBE TECHNIQUE" 87634_1 CDM 306 RC 87634 HCPCS outpatient 135 101.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 120.15 89 999999999 105.3 128.25 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); RESPIRATORY SYNCYTIAL VIRUS, AMPLIFIED PROBE TECHNIQUE" 87634_1 CDM 306 RC 87634 HCPCS outpatient 135 101.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 120.15 89 999999999 105.3 128.25 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); RESPIRATORY SYNCYTIAL VIRUS, AMPLIFIED PROBE TECHNIQUE" 87634_1 CDM 306 RC 87634 HCPCS outpatient 135 101.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 121.5 90 999999999 105.3 128.25 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); RESPIRATORY SYNCYTIAL VIRUS, AMPLIFIED PROBE TECHNIQUE" 87634_1 CDM 306 RC 87634 HCPCS outpatient 135 101.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 128.25 95 999999999 105.3 128.25 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); RESPIRATORY SYNCYTIAL VIRUS, AMPLIFIED PROBE TECHNIQUE" 87634_1 CDM 306 RC 87634 HCPCS outpatient 135 101.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 128.25 95 999999999 105.3 128.25 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); RESPIRATORY SYNCYTIAL VIRUS, AMPLIFIED PROBE TECHNIQUE" 87634_1 CDM 306 RC 87634 HCPCS outpatient 135 101.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 120.15 89 999999999 105.3 128.25 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); RESPIRATORY SYNCYTIAL VIRUS, AMPLIFIED PROBE TECHNIQUE" 87634_1 CDM 306 RC 87634 HCPCS outpatient 135 101.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 118.8 88 999999999 105.3 128.25 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); RESPIRATORY SYNCYTIAL VIRUS, AMPLIFIED PROBE TECHNIQUE" 87634_1 CDM 306 RC 87634 HCPCS outpatient 135 101.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 120.15 89 999999999 105.3 128.25 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP A, AMPLIFIED PROBE TECHNIQUE" 87651_1 CDM 300 RC 87651 HCPCS outpatient 135.5 101.63 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 121.95 90 999999999 105.69 128.73 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP A, AMPLIFIED PROBE TECHNIQUE" 87651_1 CDM 300 RC 87651 HCPCS outpatient 135.5 101.63 AETNA MCR ADV AETNA MCR ADV 105.69 78 999999999 105.69 128.73 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP A, AMPLIFIED PROBE TECHNIQUE" 87651_1 CDM 300 RC 87651 HCPCS outpatient 135.5 101.63 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 118.66 87.57 999999999 105.69 128.73 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP A, AMPLIFIED PROBE TECHNIQUE" 87651_1 CDM 300 RC 87651 HCPCS outpatient 135.5 101.63 COORDINATED CARE MCAID COORDINATED CARE MCAID 115.27 85.07 999999999 105.69 128.73 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP A, AMPLIFIED PROBE TECHNIQUE" 87651_1 CDM 300 RC 87651 HCPCS outpatient 135.5 101.63 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 115.27 85.07 999999999 105.69 128.73 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP A, AMPLIFIED PROBE TECHNIQUE" 87651_1 CDM 300 RC 87651 HCPCS outpatient 135.5 101.63 MOLINA MCAID MOLINA MCAID 113.01 83.4 999999999 105.69 128.73 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP A, AMPLIFIED PROBE TECHNIQUE" 87651_1 CDM 300 RC 87651 HCPCS outpatient 135.5 101.63 MOLINA MCR ADV MOLINA MCR ADV 120.6 89 999999999 105.69 128.73 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP A, AMPLIFIED PROBE TECHNIQUE" 87651_1 CDM 300 RC 87651 HCPCS outpatient 135.5 101.63 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 120.6 89 999999999 105.69 128.73 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP A, AMPLIFIED PROBE TECHNIQUE" 87651_1 CDM 300 RC 87651 HCPCS outpatient 135.5 101.63 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 120.6 89 999999999 105.69 128.73 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP A, AMPLIFIED PROBE TECHNIQUE" 87651_1 CDM 300 RC 87651 HCPCS outpatient 135.5 101.63 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 121.95 90 999999999 105.69 128.73 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP A, AMPLIFIED PROBE TECHNIQUE" 87651_1 CDM 300 RC 87651 HCPCS outpatient 135.5 101.63 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 128.73 95 999999999 105.69 128.73 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP A, AMPLIFIED PROBE TECHNIQUE" 87651_1 CDM 300 RC 87651 HCPCS outpatient 135.5 101.63 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 128.73 95 999999999 105.69 128.73 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP A, AMPLIFIED PROBE TECHNIQUE" 87651_1 CDM 300 RC 87651 HCPCS outpatient 135.5 101.63 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 120.6 89 999999999 105.69 128.73 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP A, AMPLIFIED PROBE TECHNIQUE" 87651_1 CDM 300 RC 87651 HCPCS outpatient 135.5 101.63 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 119.24 88 999999999 105.69 128.73 percent of total billed charges "INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP A, AMPLIFIED PROBE TECHNIQUE" 87651_1 CDM 300 RC 87651 HCPCS outpatient 135.5 101.63 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 120.6 89 999999999 105.69 128.73 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_1 CDM 306 RC 87880 HCPCS outpatient 75 56.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 67.5 90 999999999 58.5 71.25 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_1 CDM 306 RC 87880 HCPCS outpatient 75 56.25 AETNA MCR ADV AETNA MCR ADV 58.5 78 999999999 58.5 71.25 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_1 CDM 306 RC 87880 HCPCS outpatient 75 56.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 65.68 87.57 999999999 58.5 71.25 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_1 CDM 306 RC 87880 HCPCS outpatient 75 56.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 63.8 85.07 999999999 58.5 71.25 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_1 CDM 306 RC 87880 HCPCS outpatient 75 56.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 63.8 85.07 999999999 58.5 71.25 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_1 CDM 306 RC 87880 HCPCS outpatient 75 56.25 MOLINA MCAID MOLINA MCAID 62.55 83.4 999999999 58.5 71.25 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_1 CDM 306 RC 87880 HCPCS outpatient 75 56.25 MOLINA MCR ADV MOLINA MCR ADV 66.75 89 999999999 58.5 71.25 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_1 CDM 306 RC 87880 HCPCS outpatient 75 56.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 66.75 89 999999999 58.5 71.25 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_1 CDM 306 RC 87880 HCPCS outpatient 75 56.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 66.75 89 999999999 58.5 71.25 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_1 CDM 306 RC 87880 HCPCS outpatient 75 56.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 67.5 90 999999999 58.5 71.25 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_1 CDM 306 RC 87880 HCPCS outpatient 75 56.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 71.25 95 999999999 58.5 71.25 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_1 CDM 306 RC 87880 HCPCS outpatient 75 56.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 71.25 95 999999999 58.5 71.25 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_1 CDM 306 RC 87880 HCPCS outpatient 75 56.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 66.75 89 999999999 58.5 71.25 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_1 CDM 306 RC 87880 HCPCS outpatient 75 56.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 66 88 999999999 58.5 71.25 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_1 CDM 306 RC 87880 HCPCS outpatient 75 56.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 66.75 89 999999999 58.5 71.25 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_2 CDM 306 RC 87880 HCPCS outpatient 73 54.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 65.7 90 999999999 56.94 69.35 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_2 CDM 306 RC 87880 HCPCS outpatient 73 54.75 AETNA MCR ADV AETNA MCR ADV 56.94 78 999999999 56.94 69.35 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_2 CDM 306 RC 87880 HCPCS outpatient 73 54.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 63.93 87.57 999999999 56.94 69.35 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_2 CDM 306 RC 87880 HCPCS outpatient 73 54.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 62.1 85.07 999999999 56.94 69.35 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_2 CDM 306 RC 87880 HCPCS outpatient 73 54.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 62.1 85.07 999999999 56.94 69.35 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_2 CDM 306 RC 87880 HCPCS outpatient 73 54.75 MOLINA MCAID MOLINA MCAID 60.88 83.4 999999999 56.94 69.35 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_2 CDM 306 RC 87880 HCPCS outpatient 73 54.75 MOLINA MCR ADV MOLINA MCR ADV 64.97 89 999999999 56.94 69.35 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_2 CDM 306 RC 87880 HCPCS outpatient 73 54.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 64.97 89 999999999 56.94 69.35 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_2 CDM 306 RC 87880 HCPCS outpatient 73 54.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 64.97 89 999999999 56.94 69.35 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_2 CDM 306 RC 87880 HCPCS outpatient 73 54.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 65.7 90 999999999 56.94 69.35 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_2 CDM 306 RC 87880 HCPCS outpatient 73 54.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 69.35 95 999999999 56.94 69.35 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_2 CDM 306 RC 87880 HCPCS outpatient 73 54.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 69.35 95 999999999 56.94 69.35 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_2 CDM 306 RC 87880 HCPCS outpatient 73 54.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 64.97 89 999999999 56.94 69.35 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_2 CDM 306 RC 87880 HCPCS outpatient 73 54.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 64.24 88 999999999 56.94 69.35 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_2 CDM 306 RC 87880 HCPCS outpatient 73 54.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 64.97 89 999999999 56.94 69.35 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_3 CDM 306 RC 87880 HCPCS outpatient 73 54.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 65.7 90 999999999 56.94 69.35 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_3 CDM 306 RC 87880 HCPCS outpatient 73 54.75 AETNA MCR ADV AETNA MCR ADV 56.94 78 999999999 56.94 69.35 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_3 CDM 306 RC 87880 HCPCS outpatient 73 54.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 63.93 87.57 999999999 56.94 69.35 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_3 CDM 306 RC 87880 HCPCS outpatient 73 54.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 62.1 85.07 999999999 56.94 69.35 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_3 CDM 306 RC 87880 HCPCS outpatient 73 54.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 62.1 85.07 999999999 56.94 69.35 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_3 CDM 306 RC 87880 HCPCS outpatient 73 54.75 MOLINA MCAID MOLINA MCAID 60.88 83.4 999999999 56.94 69.35 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_3 CDM 306 RC 87880 HCPCS outpatient 73 54.75 MOLINA MCR ADV MOLINA MCR ADV 64.97 89 999999999 56.94 69.35 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_3 CDM 306 RC 87880 HCPCS outpatient 73 54.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 64.97 89 999999999 56.94 69.35 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_3 CDM 306 RC 87880 HCPCS outpatient 73 54.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 64.97 89 999999999 56.94 69.35 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_3 CDM 306 RC 87880 HCPCS outpatient 73 54.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 65.7 90 999999999 56.94 69.35 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_3 CDM 306 RC 87880 HCPCS outpatient 73 54.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 69.35 95 999999999 56.94 69.35 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_3 CDM 306 RC 87880 HCPCS outpatient 73 54.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 69.35 95 999999999 56.94 69.35 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_3 CDM 306 RC 87880 HCPCS outpatient 73 54.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 64.97 89 999999999 56.94 69.35 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_3 CDM 306 RC 87880 HCPCS outpatient 73 54.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 64.24 88 999999999 56.94 69.35 percent of total billed charges "INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL (IE, VISUAL) OBSERVATION; STREPTOCOCCUS, GROUP A" 87880_3 CDM 306 RC 87880 HCPCS outpatient 73 54.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 64.97 89 999999999 56.94 69.35 percent of total billed charges "CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION; MANUAL SCREENING UNDER PHYSICIAN SUPERVISION" 88142A_1 CDM 311 RC 88142 HCPCS outpatient 39 29.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 35.1 90 999999999 30.42 37.05 percent of total billed charges "CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION; MANUAL SCREENING UNDER PHYSICIAN SUPERVISION" 88142A_1 CDM 311 RC 88142 HCPCS outpatient 39 29.25 AETNA MCR ADV AETNA MCR ADV 30.42 78 999999999 30.42 37.05 percent of total billed charges "CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION; MANUAL SCREENING UNDER PHYSICIAN SUPERVISION" 88142A_1 CDM 311 RC 88142 HCPCS outpatient 39 29.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 34.15 87.57 999999999 30.42 37.05 percent of total billed charges "CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION; MANUAL SCREENING UNDER PHYSICIAN SUPERVISION" 88142A_1 CDM 311 RC 88142 HCPCS outpatient 39 29.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 33.18 85.07 999999999 30.42 37.05 percent of total billed charges "CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION; MANUAL SCREENING UNDER PHYSICIAN SUPERVISION" 88142A_1 CDM 311 RC 88142 HCPCS outpatient 39 29.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 33.18 85.07 999999999 30.42 37.05 percent of total billed charges "CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION; MANUAL SCREENING UNDER PHYSICIAN SUPERVISION" 88142A_1 CDM 311 RC 88142 HCPCS outpatient 39 29.25 MOLINA MCAID MOLINA MCAID 32.53 83.4 999999999 30.42 37.05 percent of total billed charges "CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION; MANUAL SCREENING UNDER PHYSICIAN SUPERVISION" 88142A_1 CDM 311 RC 88142 HCPCS outpatient 39 29.25 MOLINA MCR ADV MOLINA MCR ADV 34.71 89 999999999 30.42 37.05 percent of total billed charges "CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION; MANUAL SCREENING UNDER PHYSICIAN SUPERVISION" 88142A_1 CDM 311 RC 88142 HCPCS outpatient 39 29.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 34.71 89 999999999 30.42 37.05 percent of total billed charges "CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION; MANUAL SCREENING UNDER PHYSICIAN SUPERVISION" 88142A_1 CDM 311 RC 88142 HCPCS outpatient 39 29.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 34.71 89 999999999 30.42 37.05 percent of total billed charges "CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION; MANUAL SCREENING UNDER PHYSICIAN SUPERVISION" 88142A_1 CDM 311 RC 88142 HCPCS outpatient 39 29.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 35.1 90 999999999 30.42 37.05 percent of total billed charges "CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION; MANUAL SCREENING UNDER PHYSICIAN SUPERVISION" 88142A_1 CDM 311 RC 88142 HCPCS outpatient 39 29.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 37.05 95 999999999 30.42 37.05 percent of total billed charges "CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION; MANUAL SCREENING UNDER PHYSICIAN SUPERVISION" 88142A_1 CDM 311 RC 88142 HCPCS outpatient 39 29.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 37.05 95 999999999 30.42 37.05 percent of total billed charges "CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION; MANUAL SCREENING UNDER PHYSICIAN SUPERVISION" 88142A_1 CDM 311 RC 88142 HCPCS outpatient 39 29.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 34.71 89 999999999 30.42 37.05 percent of total billed charges "CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION; MANUAL SCREENING UNDER PHYSICIAN SUPERVISION" 88142A_1 CDM 311 RC 88142 HCPCS outpatient 39 29.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 34.32 88 999999999 30.42 37.05 percent of total billed charges "CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION; MANUAL SCREENING UNDER PHYSICIAN SUPERVISION" 88142A_1 CDM 311 RC 88142 HCPCS outpatient 39 29.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 34.71 89 999999999 30.42 37.05 percent of total billed charges "CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION; MANUAL SCREENING UNDER PHYSICIAN SUPERVISION" 88142A_3 CDM 311 RC 88142 HCPCS outpatient 39 29.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 35.1 90 999999999 30.42 37.05 percent of total billed charges "CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION; MANUAL SCREENING UNDER PHYSICIAN SUPERVISION" 88142A_3 CDM 311 RC 88142 HCPCS outpatient 39 29.25 AETNA MCR ADV AETNA MCR ADV 30.42 78 999999999 30.42 37.05 percent of total billed charges "CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION; MANUAL SCREENING UNDER PHYSICIAN SUPERVISION" 88142A_3 CDM 311 RC 88142 HCPCS outpatient 39 29.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 34.15 87.57 999999999 30.42 37.05 percent of total billed charges "CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION; MANUAL SCREENING UNDER PHYSICIAN SUPERVISION" 88142A_3 CDM 311 RC 88142 HCPCS outpatient 39 29.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 33.18 85.07 999999999 30.42 37.05 percent of total billed charges "CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION; MANUAL SCREENING UNDER PHYSICIAN SUPERVISION" 88142A_3 CDM 311 RC 88142 HCPCS outpatient 39 29.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 33.18 85.07 999999999 30.42 37.05 percent of total billed charges "CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION; MANUAL SCREENING UNDER PHYSICIAN SUPERVISION" 88142A_3 CDM 311 RC 88142 HCPCS outpatient 39 29.25 MOLINA MCAID MOLINA MCAID 32.53 83.4 999999999 30.42 37.05 percent of total billed charges "CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION; MANUAL SCREENING UNDER PHYSICIAN SUPERVISION" 88142A_3 CDM 311 RC 88142 HCPCS outpatient 39 29.25 MOLINA MCR ADV MOLINA MCR ADV 34.71 89 999999999 30.42 37.05 percent of total billed charges "CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION; MANUAL SCREENING UNDER PHYSICIAN SUPERVISION" 88142A_3 CDM 311 RC 88142 HCPCS outpatient 39 29.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 34.71 89 999999999 30.42 37.05 percent of total billed charges "CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION; MANUAL SCREENING UNDER PHYSICIAN SUPERVISION" 88142A_3 CDM 311 RC 88142 HCPCS outpatient 39 29.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 34.71 89 999999999 30.42 37.05 percent of total billed charges "CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION; MANUAL SCREENING UNDER PHYSICIAN SUPERVISION" 88142A_3 CDM 311 RC 88142 HCPCS outpatient 39 29.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 35.1 90 999999999 30.42 37.05 percent of total billed charges "CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION; MANUAL SCREENING UNDER PHYSICIAN SUPERVISION" 88142A_3 CDM 311 RC 88142 HCPCS outpatient 39 29.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 37.05 95 999999999 30.42 37.05 percent of total billed charges "CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION; MANUAL SCREENING UNDER PHYSICIAN SUPERVISION" 88142A_3 CDM 311 RC 88142 HCPCS outpatient 39 29.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 37.05 95 999999999 30.42 37.05 percent of total billed charges "CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION; MANUAL SCREENING UNDER PHYSICIAN SUPERVISION" 88142A_3 CDM 311 RC 88142 HCPCS outpatient 39 29.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 34.71 89 999999999 30.42 37.05 percent of total billed charges "CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION; MANUAL SCREENING UNDER PHYSICIAN SUPERVISION" 88142A_3 CDM 311 RC 88142 HCPCS outpatient 39 29.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 34.32 88 999999999 30.42 37.05 percent of total billed charges "CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION; MANUAL SCREENING UNDER PHYSICIAN SUPERVISION" 88142A_3 CDM 311 RC 88142 HCPCS outpatient 39 29.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 34.71 89 999999999 30.42 37.05 percent of total billed charges "IMMUNIZATION ADMINISTRATION THROUGH 18 YEARS OF AGE VIA ANY ROUTE OF ADMINISTRATION, WITH COUNSELING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; FIRST OR ONLY COMPONENT OF EACH VACCINE OR TOXOID ADMINISTERED" 90460_3 CDM 771 RC 90460 HCPCS outpatient 34 25.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 30.6 90 999999999 26.52 32.3 percent of total billed charges "IMMUNIZATION ADMINISTRATION THROUGH 18 YEARS OF AGE VIA ANY ROUTE OF ADMINISTRATION, WITH COUNSELING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; FIRST OR ONLY COMPONENT OF EACH VACCINE OR TOXOID ADMINISTERED" 90460_3 CDM 771 RC 90460 HCPCS outpatient 34 25.5 AETNA MCR ADV AETNA MCR ADV 26.52 78 999999999 26.52 32.3 percent of total billed charges "IMMUNIZATION ADMINISTRATION THROUGH 18 YEARS OF AGE VIA ANY ROUTE OF ADMINISTRATION, WITH COUNSELING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; FIRST OR ONLY COMPONENT OF EACH VACCINE OR TOXOID ADMINISTERED" 90460_3 CDM 771 RC 90460 HCPCS outpatient 34 25.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 29.77 87.57 999999999 26.52 32.3 percent of total billed charges "IMMUNIZATION ADMINISTRATION THROUGH 18 YEARS OF AGE VIA ANY ROUTE OF ADMINISTRATION, WITH COUNSELING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; FIRST OR ONLY COMPONENT OF EACH VACCINE OR TOXOID ADMINISTERED" 90460_3 CDM 771 RC 90460 HCPCS outpatient 34 25.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 28.92 85.07 999999999 26.52 32.3 percent of total billed charges "IMMUNIZATION ADMINISTRATION THROUGH 18 YEARS OF AGE VIA ANY ROUTE OF ADMINISTRATION, WITH COUNSELING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; FIRST OR ONLY COMPONENT OF EACH VACCINE OR TOXOID ADMINISTERED" 90460_3 CDM 771 RC 90460 HCPCS outpatient 34 25.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 28.92 85.07 999999999 26.52 32.3 percent of total billed charges "IMMUNIZATION ADMINISTRATION THROUGH 18 YEARS OF AGE VIA ANY ROUTE OF ADMINISTRATION, WITH COUNSELING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; FIRST OR ONLY COMPONENT OF EACH VACCINE OR TOXOID ADMINISTERED" 90460_3 CDM 771 RC 90460 HCPCS outpatient 34 25.5 MOLINA MCAID MOLINA MCAID 28.36 83.4 999999999 26.52 32.3 percent of total billed charges "IMMUNIZATION ADMINISTRATION THROUGH 18 YEARS OF AGE VIA ANY ROUTE OF ADMINISTRATION, WITH COUNSELING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; FIRST OR ONLY COMPONENT OF EACH VACCINE OR TOXOID ADMINISTERED" 90460_3 CDM 771 RC 90460 HCPCS outpatient 34 25.5 MOLINA MCR ADV MOLINA MCR ADV 30.26 89 999999999 26.52 32.3 percent of total billed charges "IMMUNIZATION ADMINISTRATION THROUGH 18 YEARS OF AGE VIA ANY ROUTE OF ADMINISTRATION, WITH COUNSELING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; FIRST OR ONLY COMPONENT OF EACH VACCINE OR TOXOID ADMINISTERED" 90460_3 CDM 771 RC 90460 HCPCS outpatient 34 25.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 30.26 89 999999999 26.52 32.3 percent of total billed charges "IMMUNIZATION ADMINISTRATION THROUGH 18 YEARS OF AGE VIA ANY ROUTE OF ADMINISTRATION, WITH COUNSELING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; FIRST OR ONLY COMPONENT OF EACH VACCINE OR TOXOID ADMINISTERED" 90460_3 CDM 771 RC 90460 HCPCS outpatient 34 25.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 30.26 89 999999999 26.52 32.3 percent of total billed charges "IMMUNIZATION ADMINISTRATION THROUGH 18 YEARS OF AGE VIA ANY ROUTE OF ADMINISTRATION, WITH COUNSELING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; FIRST OR ONLY COMPONENT OF EACH VACCINE OR TOXOID ADMINISTERED" 90460_3 CDM 771 RC 90460 HCPCS outpatient 34 25.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 30.6 90 999999999 26.52 32.3 percent of total billed charges "IMMUNIZATION ADMINISTRATION THROUGH 18 YEARS OF AGE VIA ANY ROUTE OF ADMINISTRATION, WITH COUNSELING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; FIRST OR ONLY COMPONENT OF EACH VACCINE OR TOXOID ADMINISTERED" 90460_3 CDM 771 RC 90460 HCPCS outpatient 34 25.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 32.3 95 999999999 26.52 32.3 percent of total billed charges "IMMUNIZATION ADMINISTRATION THROUGH 18 YEARS OF AGE VIA ANY ROUTE OF ADMINISTRATION, WITH COUNSELING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; FIRST OR ONLY COMPONENT OF EACH VACCINE OR TOXOID ADMINISTERED" 90460_3 CDM 771 RC 90460 HCPCS outpatient 34 25.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 32.3 95 999999999 26.52 32.3 percent of total billed charges "IMMUNIZATION ADMINISTRATION THROUGH 18 YEARS OF AGE VIA ANY ROUTE OF ADMINISTRATION, WITH COUNSELING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; FIRST OR ONLY COMPONENT OF EACH VACCINE OR TOXOID ADMINISTERED" 90460_3 CDM 771 RC 90460 HCPCS outpatient 34 25.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 30.26 89 999999999 26.52 32.3 percent of total billed charges "IMMUNIZATION ADMINISTRATION THROUGH 18 YEARS OF AGE VIA ANY ROUTE OF ADMINISTRATION, WITH COUNSELING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; FIRST OR ONLY COMPONENT OF EACH VACCINE OR TOXOID ADMINISTERED" 90460_3 CDM 771 RC 90460 HCPCS outpatient 34 25.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 29.92 88 999999999 26.52 32.3 percent of total billed charges "IMMUNIZATION ADMINISTRATION THROUGH 18 YEARS OF AGE VIA ANY ROUTE OF ADMINISTRATION, WITH COUNSELING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; FIRST OR ONLY COMPONENT OF EACH VACCINE OR TOXOID ADMINISTERED" 90460_3 CDM 771 RC 90460 HCPCS outpatient 34 25.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 30.26 89 999999999 26.52 32.3 percent of total billed charges "IMMUNIZATION ADMINISTRATION THROUGH 18 YEARS OF AGE VIA ANY ROUTE OF ADMINISTRATION, WITH COUNSELING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; EACH ADDITIONAL VACCINE OR TOXOID COMPONENT ADMINISTERED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 90461_3 CDM 771 RC 90461 HCPCS outpatient 26 19.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 23.4 90 999999999 20.28 24.7 percent of total billed charges "IMMUNIZATION ADMINISTRATION THROUGH 18 YEARS OF AGE VIA ANY ROUTE OF ADMINISTRATION, WITH COUNSELING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; EACH ADDITIONAL VACCINE OR TOXOID COMPONENT ADMINISTERED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 90461_3 CDM 771 RC 90461 HCPCS outpatient 26 19.5 AETNA MCR ADV AETNA MCR ADV 20.28 78 999999999 20.28 24.7 percent of total billed charges "IMMUNIZATION ADMINISTRATION THROUGH 18 YEARS OF AGE VIA ANY ROUTE OF ADMINISTRATION, WITH COUNSELING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; EACH ADDITIONAL VACCINE OR TOXOID COMPONENT ADMINISTERED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 90461_3 CDM 771 RC 90461 HCPCS outpatient 26 19.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 22.77 87.57 999999999 20.28 24.7 percent of total billed charges "IMMUNIZATION ADMINISTRATION THROUGH 18 YEARS OF AGE VIA ANY ROUTE OF ADMINISTRATION, WITH COUNSELING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; EACH ADDITIONAL VACCINE OR TOXOID COMPONENT ADMINISTERED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 90461_3 CDM 771 RC 90461 HCPCS outpatient 26 19.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 22.12 85.07 999999999 20.28 24.7 percent of total billed charges "IMMUNIZATION ADMINISTRATION THROUGH 18 YEARS OF AGE VIA ANY ROUTE OF ADMINISTRATION, WITH COUNSELING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; EACH ADDITIONAL VACCINE OR TOXOID COMPONENT ADMINISTERED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 90461_3 CDM 771 RC 90461 HCPCS outpatient 26 19.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 22.12 85.07 999999999 20.28 24.7 percent of total billed charges "IMMUNIZATION ADMINISTRATION THROUGH 18 YEARS OF AGE VIA ANY ROUTE OF ADMINISTRATION, WITH COUNSELING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; EACH ADDITIONAL VACCINE OR TOXOID COMPONENT ADMINISTERED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 90461_3 CDM 771 RC 90461 HCPCS outpatient 26 19.5 MOLINA MCAID MOLINA MCAID 21.68 83.4 999999999 20.28 24.7 percent of total billed charges "IMMUNIZATION ADMINISTRATION THROUGH 18 YEARS OF AGE VIA ANY ROUTE OF ADMINISTRATION, WITH COUNSELING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; EACH ADDITIONAL VACCINE OR TOXOID COMPONENT ADMINISTERED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 90461_3 CDM 771 RC 90461 HCPCS outpatient 26 19.5 MOLINA MCR ADV MOLINA MCR ADV 23.14 89 999999999 20.28 24.7 percent of total billed charges "IMMUNIZATION ADMINISTRATION THROUGH 18 YEARS OF AGE VIA ANY ROUTE OF ADMINISTRATION, WITH COUNSELING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; EACH ADDITIONAL VACCINE OR TOXOID COMPONENT ADMINISTERED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 90461_3 CDM 771 RC 90461 HCPCS outpatient 26 19.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 23.14 89 999999999 20.28 24.7 percent of total billed charges "IMMUNIZATION ADMINISTRATION THROUGH 18 YEARS OF AGE VIA ANY ROUTE OF ADMINISTRATION, WITH COUNSELING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; EACH ADDITIONAL VACCINE OR TOXOID COMPONENT ADMINISTERED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 90461_3 CDM 771 RC 90461 HCPCS outpatient 26 19.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 23.14 89 999999999 20.28 24.7 percent of total billed charges "IMMUNIZATION ADMINISTRATION THROUGH 18 YEARS OF AGE VIA ANY ROUTE OF ADMINISTRATION, WITH COUNSELING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; EACH ADDITIONAL VACCINE OR TOXOID COMPONENT ADMINISTERED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 90461_3 CDM 771 RC 90461 HCPCS outpatient 26 19.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 23.4 90 999999999 20.28 24.7 percent of total billed charges "IMMUNIZATION ADMINISTRATION THROUGH 18 YEARS OF AGE VIA ANY ROUTE OF ADMINISTRATION, WITH COUNSELING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; EACH ADDITIONAL VACCINE OR TOXOID COMPONENT ADMINISTERED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 90461_3 CDM 771 RC 90461 HCPCS outpatient 26 19.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 24.7 95 999999999 20.28 24.7 percent of total billed charges "IMMUNIZATION ADMINISTRATION THROUGH 18 YEARS OF AGE VIA ANY ROUTE OF ADMINISTRATION, WITH COUNSELING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; EACH ADDITIONAL VACCINE OR TOXOID COMPONENT ADMINISTERED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 90461_3 CDM 771 RC 90461 HCPCS outpatient 26 19.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 24.7 95 999999999 20.28 24.7 percent of total billed charges "IMMUNIZATION ADMINISTRATION THROUGH 18 YEARS OF AGE VIA ANY ROUTE OF ADMINISTRATION, WITH COUNSELING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; EACH ADDITIONAL VACCINE OR TOXOID COMPONENT ADMINISTERED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 90461_3 CDM 771 RC 90461 HCPCS outpatient 26 19.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 23.14 89 999999999 20.28 24.7 percent of total billed charges "IMMUNIZATION ADMINISTRATION THROUGH 18 YEARS OF AGE VIA ANY ROUTE OF ADMINISTRATION, WITH COUNSELING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; EACH ADDITIONAL VACCINE OR TOXOID COMPONENT ADMINISTERED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 90461_3 CDM 771 RC 90461 HCPCS outpatient 26 19.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 22.88 88 999999999 20.28 24.7 percent of total billed charges "IMMUNIZATION ADMINISTRATION THROUGH 18 YEARS OF AGE VIA ANY ROUTE OF ADMINISTRATION, WITH COUNSELING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; EACH ADDITIONAL VACCINE OR TOXOID COMPONENT ADMINISTERED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 90461_3 CDM 771 RC 90461 HCPCS outpatient 26 19.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 23.14 89 999999999 20.28 24.7 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 90471_3 CDM 940 RC 90471 HCPCS outpatient 34 25.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 30.6 90 999999999 26.52 32.3 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 90471_3 CDM 940 RC 90471 HCPCS outpatient 34 25.5 AETNA MCR ADV AETNA MCR ADV 26.52 78 999999999 26.52 32.3 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 90471_3 CDM 940 RC 90471 HCPCS outpatient 34 25.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 29.77 87.57 999999999 26.52 32.3 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 90471_3 CDM 940 RC 90471 HCPCS outpatient 34 25.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 28.92 85.07 999999999 26.52 32.3 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 90471_3 CDM 940 RC 90471 HCPCS outpatient 34 25.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 28.92 85.07 999999999 26.52 32.3 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 90471_3 CDM 940 RC 90471 HCPCS outpatient 34 25.5 MOLINA MCAID MOLINA MCAID 28.36 83.4 999999999 26.52 32.3 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 90471_3 CDM 940 RC 90471 HCPCS outpatient 34 25.5 MOLINA MCR ADV MOLINA MCR ADV 30.26 89 999999999 26.52 32.3 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 90471_3 CDM 940 RC 90471 HCPCS outpatient 34 25.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 30.26 89 999999999 26.52 32.3 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 90471_3 CDM 940 RC 90471 HCPCS outpatient 34 25.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 30.26 89 999999999 26.52 32.3 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 90471_3 CDM 940 RC 90471 HCPCS outpatient 34 25.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 30.6 90 999999999 26.52 32.3 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 90471_3 CDM 940 RC 90471 HCPCS outpatient 34 25.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 32.3 95 999999999 26.52 32.3 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 90471_3 CDM 940 RC 90471 HCPCS outpatient 34 25.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 32.3 95 999999999 26.52 32.3 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 90471_3 CDM 940 RC 90471 HCPCS outpatient 34 25.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 30.26 89 999999999 26.52 32.3 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 90471_3 CDM 940 RC 90471 HCPCS outpatient 34 25.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 29.92 88 999999999 26.52 32.3 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 90471_3 CDM 940 RC 90471 HCPCS outpatient 34 25.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 30.26 89 999999999 26.52 32.3 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 90472_3 CDM 940 RC 90472 HCPCS outpatient 26 19.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 23.4 90 999999999 20.28 24.7 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 90472_3 CDM 940 RC 90472 HCPCS outpatient 26 19.5 AETNA MCR ADV AETNA MCR ADV 20.28 78 999999999 20.28 24.7 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 90472_3 CDM 940 RC 90472 HCPCS outpatient 26 19.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 22.77 87.57 999999999 20.28 24.7 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 90472_3 CDM 940 RC 90472 HCPCS outpatient 26 19.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 22.12 85.07 999999999 20.28 24.7 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 90472_3 CDM 940 RC 90472 HCPCS outpatient 26 19.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 22.12 85.07 999999999 20.28 24.7 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 90472_3 CDM 940 RC 90472 HCPCS outpatient 26 19.5 MOLINA MCAID MOLINA MCAID 21.68 83.4 999999999 20.28 24.7 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 90472_3 CDM 940 RC 90472 HCPCS outpatient 26 19.5 MOLINA MCR ADV MOLINA MCR ADV 23.14 89 999999999 20.28 24.7 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 90472_3 CDM 940 RC 90472 HCPCS outpatient 26 19.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 23.14 89 999999999 20.28 24.7 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 90472_3 CDM 940 RC 90472 HCPCS outpatient 26 19.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 23.14 89 999999999 20.28 24.7 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 90472_3 CDM 940 RC 90472 HCPCS outpatient 26 19.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 23.4 90 999999999 20.28 24.7 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 90472_3 CDM 940 RC 90472 HCPCS outpatient 26 19.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 24.7 95 999999999 20.28 24.7 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 90472_3 CDM 940 RC 90472 HCPCS outpatient 26 19.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 24.7 95 999999999 20.28 24.7 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 90472_3 CDM 940 RC 90472 HCPCS outpatient 26 19.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 23.14 89 999999999 20.28 24.7 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 90472_3 CDM 940 RC 90472 HCPCS outpatient 26 19.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 22.88 88 999999999 20.28 24.7 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 90472_3 CDM 940 RC 90472 HCPCS outpatient 26 19.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 23.14 89 999999999 20.28 24.7 percent of total billed charges "ADENOVIRUS VACCINE, TYPE 4, LIVE, FOR ORAL USE" 90476_3 CDM 636 RC 90476 HCPCS outpatient 55 41.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 49.5 90 999999999 42.9 52.25 percent of total billed charges "ADENOVIRUS VACCINE, TYPE 4, LIVE, FOR ORAL USE" 90476_3 CDM 636 RC 90476 HCPCS outpatient 55 41.25 AETNA MCR ADV AETNA MCR ADV 42.9 78 999999999 42.9 52.25 percent of total billed charges "ADENOVIRUS VACCINE, TYPE 4, LIVE, FOR ORAL USE" 90476_3 CDM 636 RC 90476 HCPCS outpatient 55 41.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 48.16 87.57 999999999 42.9 52.25 percent of total billed charges "ADENOVIRUS VACCINE, TYPE 4, LIVE, FOR ORAL USE" 90476_3 CDM 636 RC 90476 HCPCS outpatient 55 41.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 46.79 85.07 999999999 42.9 52.25 percent of total billed charges "ADENOVIRUS VACCINE, TYPE 4, LIVE, FOR ORAL USE" 90476_3 CDM 636 RC 90476 HCPCS outpatient 55 41.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 46.79 85.07 999999999 42.9 52.25 percent of total billed charges "ADENOVIRUS VACCINE, TYPE 4, LIVE, FOR ORAL USE" 90476_3 CDM 636 RC 90476 HCPCS outpatient 55 41.25 MOLINA MCAID MOLINA MCAID 45.87 83.4 999999999 42.9 52.25 percent of total billed charges "ADENOVIRUS VACCINE, TYPE 4, LIVE, FOR ORAL USE" 90476_3 CDM 636 RC 90476 HCPCS outpatient 55 41.25 MOLINA MCR ADV MOLINA MCR ADV 48.95 89 999999999 42.9 52.25 percent of total billed charges "ADENOVIRUS VACCINE, TYPE 4, LIVE, FOR ORAL USE" 90476_3 CDM 636 RC 90476 HCPCS outpatient 55 41.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 48.95 89 999999999 42.9 52.25 percent of total billed charges "ADENOVIRUS VACCINE, TYPE 4, LIVE, FOR ORAL USE" 90476_3 CDM 636 RC 90476 HCPCS outpatient 55 41.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 48.95 89 999999999 42.9 52.25 percent of total billed charges "ADENOVIRUS VACCINE, TYPE 4, LIVE, FOR ORAL USE" 90476_3 CDM 636 RC 90476 HCPCS outpatient 55 41.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 49.5 90 999999999 42.9 52.25 percent of total billed charges "ADENOVIRUS VACCINE, TYPE 4, LIVE, FOR ORAL USE" 90476_3 CDM 636 RC 90476 HCPCS outpatient 55 41.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 52.25 95 999999999 42.9 52.25 percent of total billed charges "ADENOVIRUS VACCINE, TYPE 4, LIVE, FOR ORAL USE" 90476_3 CDM 636 RC 90476 HCPCS outpatient 55 41.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 52.25 95 999999999 42.9 52.25 percent of total billed charges "ADENOVIRUS VACCINE, TYPE 4, LIVE, FOR ORAL USE" 90476_3 CDM 636 RC 90476 HCPCS outpatient 55 41.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 48.95 89 999999999 42.9 52.25 percent of total billed charges "ADENOVIRUS VACCINE, TYPE 4, LIVE, FOR ORAL USE" 90476_3 CDM 636 RC 90476 HCPCS outpatient 55 41.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 48.4 88 999999999 42.9 52.25 percent of total billed charges "ADENOVIRUS VACCINE, TYPE 4, LIVE, FOR ORAL USE" 90476_3 CDM 636 RC 90476 HCPCS outpatient 55 41.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 48.95 89 999999999 42.9 52.25 percent of total billed charges "HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUSCULAR USE" 90632_3 CDM 636 RC 90632 HCPCS outpatient 104 78 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 93.6 90 999999999 81.12 98.8 percent of total billed charges "HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUSCULAR USE" 90632_3 CDM 636 RC 90632 HCPCS outpatient 104 78 AETNA MCR ADV AETNA MCR ADV 81.12 78 999999999 81.12 98.8 percent of total billed charges "HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUSCULAR USE" 90632_3 CDM 636 RC 90632 HCPCS outpatient 104 78 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 91.07 87.57 999999999 81.12 98.8 percent of total billed charges "HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUSCULAR USE" 90632_3 CDM 636 RC 90632 HCPCS outpatient 104 78 COORDINATED CARE MCAID COORDINATED CARE MCAID 88.47 85.07 999999999 81.12 98.8 percent of total billed charges "HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUSCULAR USE" 90632_3 CDM 636 RC 90632 HCPCS outpatient 104 78 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 88.47 85.07 999999999 81.12 98.8 percent of total billed charges "HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUSCULAR USE" 90632_3 CDM 636 RC 90632 HCPCS outpatient 104 78 MOLINA MCAID MOLINA MCAID 86.74 83.4 999999999 81.12 98.8 percent of total billed charges "HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUSCULAR USE" 90632_3 CDM 636 RC 90632 HCPCS outpatient 104 78 MOLINA MCR ADV MOLINA MCR ADV 92.56 89 999999999 81.12 98.8 percent of total billed charges "HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUSCULAR USE" 90632_3 CDM 636 RC 90632 HCPCS outpatient 104 78 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 92.56 89 999999999 81.12 98.8 percent of total billed charges "HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUSCULAR USE" 90632_3 CDM 636 RC 90632 HCPCS outpatient 104 78 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 92.56 89 999999999 81.12 98.8 percent of total billed charges "HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUSCULAR USE" 90632_3 CDM 636 RC 90632 HCPCS outpatient 104 78 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 93.6 90 999999999 81.12 98.8 percent of total billed charges "HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUSCULAR USE" 90632_3 CDM 636 RC 90632 HCPCS outpatient 104 78 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 98.8 95 999999999 81.12 98.8 percent of total billed charges "HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUSCULAR USE" 90632_3 CDM 636 RC 90632 HCPCS outpatient 104 78 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 98.8 95 999999999 81.12 98.8 percent of total billed charges "HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUSCULAR USE" 90632_3 CDM 636 RC 90632 HCPCS outpatient 104 78 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 92.56 89 999999999 81.12 98.8 percent of total billed charges "HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUSCULAR USE" 90632_3 CDM 636 RC 90632 HCPCS outpatient 104 78 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 91.52 88 999999999 81.12 98.8 percent of total billed charges "HEPATITIS A VACCINE (HEPA), ADULT DOSAGE, FOR INTRAMUSCULAR USE" 90632_3 CDM 636 RC 90632 HCPCS outpatient 104 78 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 92.56 89 999999999 81.12 98.8 percent of total billed charges "HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT DOSAGE-2 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90633_3 CDM 636 RC 00064-0950-10 NDC 90633 HCPCS outpatient 1 EA 20 15 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 18 90 999999999 15.6 19 percent of total billed charges "HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT DOSAGE-2 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90633_3 CDM 636 RC 00064-0950-10 NDC 90633 HCPCS outpatient 1 EA 20 15 AETNA MCR ADV AETNA MCR ADV 15.6 78 999999999 15.6 19 percent of total billed charges "HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT DOSAGE-2 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90633_3 CDM 636 RC 00064-0950-10 NDC 90633 HCPCS outpatient 1 EA 20 15 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 17.51 87.57 999999999 15.6 19 percent of total billed charges "HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT DOSAGE-2 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90633_3 CDM 636 RC 00064-0950-10 NDC 90633 HCPCS outpatient 1 EA 20 15 COORDINATED CARE MCAID COORDINATED CARE MCAID 17.01 85.07 999999999 15.6 19 percent of total billed charges "HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT DOSAGE-2 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90633_3 CDM 636 RC 00064-0950-10 NDC 90633 HCPCS outpatient 1 EA 20 15 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 17.01 85.07 999999999 15.6 19 percent of total billed charges "HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT DOSAGE-2 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90633_3 CDM 636 RC 00064-0950-10 NDC 90633 HCPCS outpatient 1 EA 20 15 MOLINA MCAID MOLINA MCAID 16.68 83.4 999999999 15.6 19 percent of total billed charges "HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT DOSAGE-2 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90633_3 CDM 636 RC 00064-0950-10 NDC 90633 HCPCS outpatient 1 EA 20 15 MOLINA MCR ADV MOLINA MCR ADV 17.8 89 999999999 15.6 19 percent of total billed charges "HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT DOSAGE-2 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90633_3 CDM 636 RC 00064-0950-10 NDC 90633 HCPCS outpatient 1 EA 20 15 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT DOSAGE-2 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90633_3 CDM 636 RC 00064-0950-10 NDC 90633 HCPCS outpatient 1 EA 20 15 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT DOSAGE-2 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90633_3 CDM 636 RC 00064-0950-10 NDC 90633 HCPCS outpatient 1 EA 20 15 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 18 90 999999999 15.6 19 percent of total billed charges "HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT DOSAGE-2 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90633_3 CDM 636 RC 00064-0950-10 NDC 90633 HCPCS outpatient 1 EA 20 15 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 19 95 999999999 15.6 19 percent of total billed charges "HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT DOSAGE-2 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90633_3 CDM 636 RC 00064-0950-10 NDC 90633 HCPCS outpatient 1 EA 20 15 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 19 95 999999999 15.6 19 percent of total billed charges "HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT DOSAGE-2 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90633_3 CDM 636 RC 00064-0950-10 NDC 90633 HCPCS outpatient 1 EA 20 15 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 17.8 89 999999999 15.6 19 percent of total billed charges "HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT DOSAGE-2 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90633_3 CDM 636 RC 00064-0950-10 NDC 90633 HCPCS outpatient 1 EA 20 15 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 17.6 88 999999999 15.6 19 percent of total billed charges "HEPATITIS A VACCINE (HEPA), PEDIATRIC/ADOLESCENT DOSAGE-2 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90633_3 CDM 636 RC 00064-0950-10 NDC 90633 HCPCS outpatient 1 EA 20 15 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP-T CONJUGATE, 4 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90648_3 CDM 250 RC 90648 HCPCS outpatient 20 15 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 18 90 999999999 15.6 19 percent of total billed charges "HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP-T CONJUGATE, 4 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90648_3 CDM 250 RC 90648 HCPCS outpatient 20 15 AETNA MCR ADV AETNA MCR ADV 15.6 78 999999999 15.6 19 percent of total billed charges "HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP-T CONJUGATE, 4 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90648_3 CDM 250 RC 90648 HCPCS outpatient 20 15 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 17.51 87.57 999999999 15.6 19 percent of total billed charges "HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP-T CONJUGATE, 4 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90648_3 CDM 250 RC 90648 HCPCS outpatient 20 15 COORDINATED CARE MCAID COORDINATED CARE MCAID 17.01 85.07 999999999 15.6 19 percent of total billed charges "HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP-T CONJUGATE, 4 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90648_3 CDM 250 RC 90648 HCPCS outpatient 20 15 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 17.01 85.07 999999999 15.6 19 percent of total billed charges "HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP-T CONJUGATE, 4 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90648_3 CDM 250 RC 90648 HCPCS outpatient 20 15 MOLINA MCAID MOLINA MCAID 16.68 83.4 999999999 15.6 19 percent of total billed charges "HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP-T CONJUGATE, 4 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90648_3 CDM 250 RC 90648 HCPCS outpatient 20 15 MOLINA MCR ADV MOLINA MCR ADV 17.8 89 999999999 15.6 19 percent of total billed charges "HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP-T CONJUGATE, 4 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90648_3 CDM 250 RC 90648 HCPCS outpatient 20 15 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP-T CONJUGATE, 4 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90648_3 CDM 250 RC 90648 HCPCS outpatient 20 15 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP-T CONJUGATE, 4 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90648_3 CDM 250 RC 90648 HCPCS outpatient 20 15 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 18 90 999999999 15.6 19 percent of total billed charges "HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP-T CONJUGATE, 4 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90648_3 CDM 250 RC 90648 HCPCS outpatient 20 15 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 19 95 999999999 15.6 19 percent of total billed charges "HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP-T CONJUGATE, 4 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90648_3 CDM 250 RC 90648 HCPCS outpatient 20 15 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 19 95 999999999 15.6 19 percent of total billed charges "HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP-T CONJUGATE, 4 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90648_3 CDM 250 RC 90648 HCPCS outpatient 20 15 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 17.8 89 999999999 15.6 19 percent of total billed charges "HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP-T CONJUGATE, 4 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90648_3 CDM 250 RC 90648 HCPCS outpatient 20 15 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 17.6 88 999999999 15.6 19 percent of total billed charges "HAEMOPHILUS INFLUENZAE TYPE B VACCINE (HIB), PRP-T CONJUGATE, 4 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90648_3 CDM 250 RC 90648 HCPCS outpatient 20 15 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE, TYPES 6, 11, 16, 18, QUADRIVALENT (4VHPV), 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90649_3 CDM 636 RC 90649 HCPCS outpatient 20 15 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 18 90 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE, TYPES 6, 11, 16, 18, QUADRIVALENT (4VHPV), 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90649_3 CDM 636 RC 90649 HCPCS outpatient 20 15 AETNA MCR ADV AETNA MCR ADV 15.6 78 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE, TYPES 6, 11, 16, 18, QUADRIVALENT (4VHPV), 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90649_3 CDM 636 RC 90649 HCPCS outpatient 20 15 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 17.51 87.57 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE, TYPES 6, 11, 16, 18, QUADRIVALENT (4VHPV), 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90649_3 CDM 636 RC 90649 HCPCS outpatient 20 15 COORDINATED CARE MCAID COORDINATED CARE MCAID 17.01 85.07 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE, TYPES 6, 11, 16, 18, QUADRIVALENT (4VHPV), 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90649_3 CDM 636 RC 90649 HCPCS outpatient 20 15 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 17.01 85.07 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE, TYPES 6, 11, 16, 18, QUADRIVALENT (4VHPV), 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90649_3 CDM 636 RC 90649 HCPCS outpatient 20 15 MOLINA MCAID MOLINA MCAID 16.68 83.4 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE, TYPES 6, 11, 16, 18, QUADRIVALENT (4VHPV), 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90649_3 CDM 636 RC 90649 HCPCS outpatient 20 15 MOLINA MCR ADV MOLINA MCR ADV 17.8 89 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE, TYPES 6, 11, 16, 18, QUADRIVALENT (4VHPV), 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90649_3 CDM 636 RC 90649 HCPCS outpatient 20 15 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE, TYPES 6, 11, 16, 18, QUADRIVALENT (4VHPV), 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90649_3 CDM 636 RC 90649 HCPCS outpatient 20 15 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE, TYPES 6, 11, 16, 18, QUADRIVALENT (4VHPV), 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90649_3 CDM 636 RC 90649 HCPCS outpatient 20 15 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 18 90 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE, TYPES 6, 11, 16, 18, QUADRIVALENT (4VHPV), 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90649_3 CDM 636 RC 90649 HCPCS outpatient 20 15 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 19 95 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE, TYPES 6, 11, 16, 18, QUADRIVALENT (4VHPV), 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90649_3 CDM 636 RC 90649 HCPCS outpatient 20 15 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 19 95 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE, TYPES 6, 11, 16, 18, QUADRIVALENT (4VHPV), 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90649_3 CDM 636 RC 90649 HCPCS outpatient 20 15 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 17.8 89 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE, TYPES 6, 11, 16, 18, QUADRIVALENT (4VHPV), 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90649_3 CDM 636 RC 90649 HCPCS outpatient 20 15 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 17.6 88 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE, TYPES 6, 11, 16, 18, QUADRIVALENT (4VHPV), 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90649_3 CDM 636 RC 90649 HCPCS outpatient 20 15 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE, TYPES 16, 18, BIVALENT (2VHPV), 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90650_3 CDM 250 RC 90650 HCPCS outpatient 20 15 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 18 90 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE, TYPES 16, 18, BIVALENT (2VHPV), 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90650_3 CDM 250 RC 90650 HCPCS outpatient 20 15 AETNA MCR ADV AETNA MCR ADV 15.6 78 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE, TYPES 16, 18, BIVALENT (2VHPV), 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90650_3 CDM 250 RC 90650 HCPCS outpatient 20 15 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 17.51 87.57 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE, TYPES 16, 18, BIVALENT (2VHPV), 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90650_3 CDM 250 RC 90650 HCPCS outpatient 20 15 COORDINATED CARE MCAID COORDINATED CARE MCAID 17.01 85.07 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE, TYPES 16, 18, BIVALENT (2VHPV), 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90650_3 CDM 250 RC 90650 HCPCS outpatient 20 15 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 17.01 85.07 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE, TYPES 16, 18, BIVALENT (2VHPV), 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90650_3 CDM 250 RC 90650 HCPCS outpatient 20 15 MOLINA MCAID MOLINA MCAID 16.68 83.4 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE, TYPES 16, 18, BIVALENT (2VHPV), 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90650_3 CDM 250 RC 90650 HCPCS outpatient 20 15 MOLINA MCR ADV MOLINA MCR ADV 17.8 89 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE, TYPES 16, 18, BIVALENT (2VHPV), 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90650_3 CDM 250 RC 90650 HCPCS outpatient 20 15 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE, TYPES 16, 18, BIVALENT (2VHPV), 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90650_3 CDM 250 RC 90650 HCPCS outpatient 20 15 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE, TYPES 16, 18, BIVALENT (2VHPV), 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90650_3 CDM 250 RC 90650 HCPCS outpatient 20 15 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 18 90 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE, TYPES 16, 18, BIVALENT (2VHPV), 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90650_3 CDM 250 RC 90650 HCPCS outpatient 20 15 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 19 95 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE, TYPES 16, 18, BIVALENT (2VHPV), 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90650_3 CDM 250 RC 90650 HCPCS outpatient 20 15 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 19 95 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE, TYPES 16, 18, BIVALENT (2VHPV), 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90650_3 CDM 250 RC 90650 HCPCS outpatient 20 15 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 17.8 89 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE, TYPES 16, 18, BIVALENT (2VHPV), 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90650_3 CDM 250 RC 90650 HCPCS outpatient 20 15 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 17.6 88 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE, TYPES 16, 18, BIVALENT (2VHPV), 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90650_3 CDM 250 RC 90650 HCPCS outpatient 20 15 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE TYPES 6, 11, 16, 18, 31, 33, 45, 52, 58, NONAVALENT (9VHPV), 2 OR 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90651_3 CDM 250 RC 00006-4119-03 NDC 90651 HCPCS outpatient 0.5 EA 20 15 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 18 90 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE TYPES 6, 11, 16, 18, 31, 33, 45, 52, 58, NONAVALENT (9VHPV), 2 OR 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90651_3 CDM 250 RC 00006-4119-03 NDC 90651 HCPCS outpatient 0.5 EA 20 15 AETNA MCR ADV AETNA MCR ADV 15.6 78 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE TYPES 6, 11, 16, 18, 31, 33, 45, 52, 58, NONAVALENT (9VHPV), 2 OR 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90651_3 CDM 250 RC 00006-4119-03 NDC 90651 HCPCS outpatient 0.5 EA 20 15 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 17.51 87.57 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE TYPES 6, 11, 16, 18, 31, 33, 45, 52, 58, NONAVALENT (9VHPV), 2 OR 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90651_3 CDM 250 RC 00006-4119-03 NDC 90651 HCPCS outpatient 0.5 EA 20 15 COORDINATED CARE MCAID COORDINATED CARE MCAID 17.01 85.07 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE TYPES 6, 11, 16, 18, 31, 33, 45, 52, 58, NONAVALENT (9VHPV), 2 OR 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90651_3 CDM 250 RC 00006-4119-03 NDC 90651 HCPCS outpatient 0.5 EA 20 15 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 17.01 85.07 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE TYPES 6, 11, 16, 18, 31, 33, 45, 52, 58, NONAVALENT (9VHPV), 2 OR 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90651_3 CDM 250 RC 00006-4119-03 NDC 90651 HCPCS outpatient 0.5 EA 20 15 MOLINA MCAID MOLINA MCAID 16.68 83.4 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE TYPES 6, 11, 16, 18, 31, 33, 45, 52, 58, NONAVALENT (9VHPV), 2 OR 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90651_3 CDM 250 RC 00006-4119-03 NDC 90651 HCPCS outpatient 0.5 EA 20 15 MOLINA MCR ADV MOLINA MCR ADV 17.8 89 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE TYPES 6, 11, 16, 18, 31, 33, 45, 52, 58, NONAVALENT (9VHPV), 2 OR 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90651_3 CDM 250 RC 00006-4119-03 NDC 90651 HCPCS outpatient 0.5 EA 20 15 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE TYPES 6, 11, 16, 18, 31, 33, 45, 52, 58, NONAVALENT (9VHPV), 2 OR 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90651_3 CDM 250 RC 00006-4119-03 NDC 90651 HCPCS outpatient 0.5 EA 20 15 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE TYPES 6, 11, 16, 18, 31, 33, 45, 52, 58, NONAVALENT (9VHPV), 2 OR 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90651_3 CDM 250 RC 00006-4119-03 NDC 90651 HCPCS outpatient 0.5 EA 20 15 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 18 90 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE TYPES 6, 11, 16, 18, 31, 33, 45, 52, 58, NONAVALENT (9VHPV), 2 OR 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90651_3 CDM 250 RC 00006-4119-03 NDC 90651 HCPCS outpatient 0.5 EA 20 15 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 19 95 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE TYPES 6, 11, 16, 18, 31, 33, 45, 52, 58, NONAVALENT (9VHPV), 2 OR 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90651_3 CDM 250 RC 00006-4119-03 NDC 90651 HCPCS outpatient 0.5 EA 20 15 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 19 95 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE TYPES 6, 11, 16, 18, 31, 33, 45, 52, 58, NONAVALENT (9VHPV), 2 OR 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90651_3 CDM 250 RC 00006-4119-03 NDC 90651 HCPCS outpatient 0.5 EA 20 15 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 17.8 89 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE TYPES 6, 11, 16, 18, 31, 33, 45, 52, 58, NONAVALENT (9VHPV), 2 OR 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90651_3 CDM 250 RC 00006-4119-03 NDC 90651 HCPCS outpatient 0.5 EA 20 15 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 17.6 88 999999999 15.6 19 percent of total billed charges "HUMAN PAPILLOMAVIRUS VACCINE TYPES 6, 11, 16, 18, 31, 33, 45, 52, 58, NONAVALENT (9VHPV), 2 OR 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90651_3 CDM 250 RC 00006-4119-03 NDC 90651 HCPCS outpatient 0.5 EA 20 15 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, PRESERVATIVE FREE, 0.25 ML DOSAGE, FOR INTRAMUSCULAR USE" 90655_3 CDM 636 RC 90655 HCPCS outpatient 21 15.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 18.9 90 999999999 16.38 19.95 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, PRESERVATIVE FREE, 0.25 ML DOSAGE, FOR INTRAMUSCULAR USE" 90655_3 CDM 636 RC 90655 HCPCS outpatient 21 15.75 AETNA MCR ADV AETNA MCR ADV 16.38 78 999999999 16.38 19.95 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, PRESERVATIVE FREE, 0.25 ML DOSAGE, FOR INTRAMUSCULAR USE" 90655_3 CDM 636 RC 90655 HCPCS outpatient 21 15.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 18.39 87.57 999999999 16.38 19.95 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, PRESERVATIVE FREE, 0.25 ML DOSAGE, FOR INTRAMUSCULAR USE" 90655_3 CDM 636 RC 90655 HCPCS outpatient 21 15.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 17.86 85.07 999999999 16.38 19.95 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, PRESERVATIVE FREE, 0.25 ML DOSAGE, FOR INTRAMUSCULAR USE" 90655_3 CDM 636 RC 90655 HCPCS outpatient 21 15.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 17.86 85.07 999999999 16.38 19.95 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, PRESERVATIVE FREE, 0.25 ML DOSAGE, FOR INTRAMUSCULAR USE" 90655_3 CDM 636 RC 90655 HCPCS outpatient 21 15.75 MOLINA MCAID MOLINA MCAID 17.51 83.4 999999999 16.38 19.95 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, PRESERVATIVE FREE, 0.25 ML DOSAGE, FOR INTRAMUSCULAR USE" 90655_3 CDM 636 RC 90655 HCPCS outpatient 21 15.75 MOLINA MCR ADV MOLINA MCR ADV 18.69 89 999999999 16.38 19.95 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, PRESERVATIVE FREE, 0.25 ML DOSAGE, FOR INTRAMUSCULAR USE" 90655_3 CDM 636 RC 90655 HCPCS outpatient 21 15.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 18.69 89 999999999 16.38 19.95 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, PRESERVATIVE FREE, 0.25 ML DOSAGE, FOR INTRAMUSCULAR USE" 90655_3 CDM 636 RC 90655 HCPCS outpatient 21 15.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 18.69 89 999999999 16.38 19.95 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, PRESERVATIVE FREE, 0.25 ML DOSAGE, FOR INTRAMUSCULAR USE" 90655_3 CDM 636 RC 90655 HCPCS outpatient 21 15.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 18.9 90 999999999 16.38 19.95 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, PRESERVATIVE FREE, 0.25 ML DOSAGE, FOR INTRAMUSCULAR USE" 90655_3 CDM 636 RC 90655 HCPCS outpatient 21 15.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 19.95 95 999999999 16.38 19.95 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, PRESERVATIVE FREE, 0.25 ML DOSAGE, FOR INTRAMUSCULAR USE" 90655_3 CDM 636 RC 90655 HCPCS outpatient 21 15.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 19.95 95 999999999 16.38 19.95 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, PRESERVATIVE FREE, 0.25 ML DOSAGE, FOR INTRAMUSCULAR USE" 90655_3 CDM 636 RC 90655 HCPCS outpatient 21 15.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 18.69 89 999999999 16.38 19.95 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, PRESERVATIVE FREE, 0.25 ML DOSAGE, FOR INTRAMUSCULAR USE" 90655_3 CDM 636 RC 90655 HCPCS outpatient 21 15.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 18.48 88 999999999 16.38 19.95 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, PRESERVATIVE FREE, 0.25 ML DOSAGE, FOR INTRAMUSCULAR USE" 90655_3 CDM 636 RC 90655 HCPCS outpatient 21 15.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 18.69 89 999999999 16.38 19.95 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, 0.25 ML DOSAGE, FOR INTRAMUSCULAR USE" 90657_3 CDM 636 RC 90657 HCPCS outpatient 15 11.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 13.5 90 999999999 11.7 14.25 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, 0.25 ML DOSAGE, FOR INTRAMUSCULAR USE" 90657_3 CDM 636 RC 90657 HCPCS outpatient 15 11.25 AETNA MCR ADV AETNA MCR ADV 11.7 78 999999999 11.7 14.25 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, 0.25 ML DOSAGE, FOR INTRAMUSCULAR USE" 90657_3 CDM 636 RC 90657 HCPCS outpatient 15 11.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 13.14 87.57 999999999 11.7 14.25 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, 0.25 ML DOSAGE, FOR INTRAMUSCULAR USE" 90657_3 CDM 636 RC 90657 HCPCS outpatient 15 11.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 12.76 85.07 999999999 11.7 14.25 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, 0.25 ML DOSAGE, FOR INTRAMUSCULAR USE" 90657_3 CDM 636 RC 90657 HCPCS outpatient 15 11.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 12.76 85.07 999999999 11.7 14.25 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, 0.25 ML DOSAGE, FOR INTRAMUSCULAR USE" 90657_3 CDM 636 RC 90657 HCPCS outpatient 15 11.25 MOLINA MCAID MOLINA MCAID 12.51 83.4 999999999 11.7 14.25 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, 0.25 ML DOSAGE, FOR INTRAMUSCULAR USE" 90657_3 CDM 636 RC 90657 HCPCS outpatient 15 11.25 MOLINA MCR ADV MOLINA MCR ADV 13.35 89 999999999 11.7 14.25 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, 0.25 ML DOSAGE, FOR INTRAMUSCULAR USE" 90657_3 CDM 636 RC 90657 HCPCS outpatient 15 11.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 13.35 89 999999999 11.7 14.25 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, 0.25 ML DOSAGE, FOR INTRAMUSCULAR USE" 90657_3 CDM 636 RC 90657 HCPCS outpatient 15 11.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 13.35 89 999999999 11.7 14.25 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, 0.25 ML DOSAGE, FOR INTRAMUSCULAR USE" 90657_3 CDM 636 RC 90657 HCPCS outpatient 15 11.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 13.5 90 999999999 11.7 14.25 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, 0.25 ML DOSAGE, FOR INTRAMUSCULAR USE" 90657_3 CDM 636 RC 90657 HCPCS outpatient 15 11.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 14.25 95 999999999 11.7 14.25 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, 0.25 ML DOSAGE, FOR INTRAMUSCULAR USE" 90657_3 CDM 636 RC 90657 HCPCS outpatient 15 11.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 14.25 95 999999999 11.7 14.25 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, 0.25 ML DOSAGE, FOR INTRAMUSCULAR USE" 90657_3 CDM 636 RC 90657 HCPCS outpatient 15 11.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 13.35 89 999999999 11.7 14.25 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, 0.25 ML DOSAGE, FOR INTRAMUSCULAR USE" 90657_3 CDM 636 RC 90657 HCPCS outpatient 15 11.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 13.2 88 999999999 11.7 14.25 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, 0.25 ML DOSAGE, FOR INTRAMUSCULAR USE" 90657_3 CDM 636 RC 90657 HCPCS outpatient 15 11.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 13.35 89 999999999 11.7 14.25 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 90658_3 CDM 636 RC 90658 HCPCS outpatient 26 19.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 23.4 90 999999999 20.28 24.7 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 90658_3 CDM 636 RC 90658 HCPCS outpatient 26 19.5 AETNA MCR ADV AETNA MCR ADV 20.28 78 999999999 20.28 24.7 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 90658_3 CDM 636 RC 90658 HCPCS outpatient 26 19.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 22.77 87.57 999999999 20.28 24.7 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 90658_3 CDM 636 RC 90658 HCPCS outpatient 26 19.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 22.12 85.07 999999999 20.28 24.7 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 90658_3 CDM 636 RC 90658 HCPCS outpatient 26 19.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 22.12 85.07 999999999 20.28 24.7 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 90658_3 CDM 636 RC 90658 HCPCS outpatient 26 19.5 MOLINA MCAID MOLINA MCAID 21.68 83.4 999999999 20.28 24.7 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 90658_3 CDM 636 RC 90658 HCPCS outpatient 26 19.5 MOLINA MCR ADV MOLINA MCR ADV 23.14 89 999999999 20.28 24.7 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 90658_3 CDM 636 RC 90658 HCPCS outpatient 26 19.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 23.14 89 999999999 20.28 24.7 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 90658_3 CDM 636 RC 90658 HCPCS outpatient 26 19.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 23.14 89 999999999 20.28 24.7 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 90658_3 CDM 636 RC 90658 HCPCS outpatient 26 19.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 23.4 90 999999999 20.28 24.7 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 90658_3 CDM 636 RC 90658 HCPCS outpatient 26 19.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 24.7 95 999999999 20.28 24.7 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 90658_3 CDM 636 RC 90658 HCPCS outpatient 26 19.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 24.7 95 999999999 20.28 24.7 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 90658_3 CDM 636 RC 90658 HCPCS outpatient 26 19.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 23.14 89 999999999 20.28 24.7 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 90658_3 CDM 636 RC 90658 HCPCS outpatient 26 19.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 22.88 88 999999999 20.28 24.7 percent of total billed charges "INFLUENZA VIRUS VACCINE, TRIVALENT (IIV3), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 90658_3 CDM 636 RC 90658 HCPCS outpatient 26 19.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 23.14 89 999999999 20.28 24.7 percent of total billed charges "INFLUENZA VIRUS VACCINE (IIV), SPLIT VIRUS, PRESERVATIVE FREE, ENHANCED IMMUNOGENICITY VIA INCREASED ANTIGEN CONTENT, FOR INTRAMUSCULAR USE" 90662_3 CDM 636 RC 49281-0121-65 NDC 90662 HCPCS outpatient 240 EA 57 42.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 51.3 90 999999999 44.46 54.15 percent of total billed charges "INFLUENZA VIRUS VACCINE (IIV), SPLIT VIRUS, PRESERVATIVE FREE, ENHANCED IMMUNOGENICITY VIA INCREASED ANTIGEN CONTENT, FOR INTRAMUSCULAR USE" 90662_3 CDM 636 RC 49281-0121-65 NDC 90662 HCPCS outpatient 240 EA 57 42.75 AETNA MCR ADV AETNA MCR ADV 44.46 78 999999999 44.46 54.15 percent of total billed charges "INFLUENZA VIRUS VACCINE (IIV), SPLIT VIRUS, PRESERVATIVE FREE, ENHANCED IMMUNOGENICITY VIA INCREASED ANTIGEN CONTENT, FOR INTRAMUSCULAR USE" 90662_3 CDM 636 RC 49281-0121-65 NDC 90662 HCPCS outpatient 240 EA 57 42.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 49.91 87.57 999999999 44.46 54.15 percent of total billed charges "INFLUENZA VIRUS VACCINE (IIV), SPLIT VIRUS, PRESERVATIVE FREE, ENHANCED IMMUNOGENICITY VIA INCREASED ANTIGEN CONTENT, FOR INTRAMUSCULAR USE" 90662_3 CDM 636 RC 49281-0121-65 NDC 90662 HCPCS outpatient 240 EA 57 42.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 48.49 85.07 999999999 44.46 54.15 percent of total billed charges "INFLUENZA VIRUS VACCINE (IIV), SPLIT VIRUS, PRESERVATIVE FREE, ENHANCED IMMUNOGENICITY VIA INCREASED ANTIGEN CONTENT, FOR INTRAMUSCULAR USE" 90662_3 CDM 636 RC 49281-0121-65 NDC 90662 HCPCS outpatient 240 EA 57 42.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 48.49 85.07 999999999 44.46 54.15 percent of total billed charges "INFLUENZA VIRUS VACCINE (IIV), SPLIT VIRUS, PRESERVATIVE FREE, ENHANCED IMMUNOGENICITY VIA INCREASED ANTIGEN CONTENT, FOR INTRAMUSCULAR USE" 90662_3 CDM 636 RC 49281-0121-65 NDC 90662 HCPCS outpatient 240 EA 57 42.75 MOLINA MCAID MOLINA MCAID 47.54 83.4 999999999 44.46 54.15 percent of total billed charges "INFLUENZA VIRUS VACCINE (IIV), SPLIT VIRUS, PRESERVATIVE FREE, ENHANCED IMMUNOGENICITY VIA INCREASED ANTIGEN CONTENT, FOR INTRAMUSCULAR USE" 90662_3 CDM 636 RC 49281-0121-65 NDC 90662 HCPCS outpatient 240 EA 57 42.75 MOLINA MCR ADV MOLINA MCR ADV 50.73 89 999999999 44.46 54.15 percent of total billed charges "INFLUENZA VIRUS VACCINE (IIV), SPLIT VIRUS, PRESERVATIVE FREE, ENHANCED IMMUNOGENICITY VIA INCREASED ANTIGEN CONTENT, FOR INTRAMUSCULAR USE" 90662_3 CDM 636 RC 49281-0121-65 NDC 90662 HCPCS outpatient 240 EA 57 42.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50.73 89 999999999 44.46 54.15 percent of total billed charges "INFLUENZA VIRUS VACCINE (IIV), SPLIT VIRUS, PRESERVATIVE FREE, ENHANCED IMMUNOGENICITY VIA INCREASED ANTIGEN CONTENT, FOR INTRAMUSCULAR USE" 90662_3 CDM 636 RC 49281-0121-65 NDC 90662 HCPCS outpatient 240 EA 57 42.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50.73 89 999999999 44.46 54.15 percent of total billed charges "INFLUENZA VIRUS VACCINE (IIV), SPLIT VIRUS, PRESERVATIVE FREE, ENHANCED IMMUNOGENICITY VIA INCREASED ANTIGEN CONTENT, FOR INTRAMUSCULAR USE" 90662_3 CDM 636 RC 49281-0121-65 NDC 90662 HCPCS outpatient 240 EA 57 42.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 51.3 90 999999999 44.46 54.15 percent of total billed charges "INFLUENZA VIRUS VACCINE (IIV), SPLIT VIRUS, PRESERVATIVE FREE, ENHANCED IMMUNOGENICITY VIA INCREASED ANTIGEN CONTENT, FOR INTRAMUSCULAR USE" 90662_3 CDM 636 RC 49281-0121-65 NDC 90662 HCPCS outpatient 240 EA 57 42.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 54.15 95 999999999 44.46 54.15 percent of total billed charges "INFLUENZA VIRUS VACCINE (IIV), SPLIT VIRUS, PRESERVATIVE FREE, ENHANCED IMMUNOGENICITY VIA INCREASED ANTIGEN CONTENT, FOR INTRAMUSCULAR USE" 90662_3 CDM 636 RC 49281-0121-65 NDC 90662 HCPCS outpatient 240 EA 57 42.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 54.15 95 999999999 44.46 54.15 percent of total billed charges "INFLUENZA VIRUS VACCINE (IIV), SPLIT VIRUS, PRESERVATIVE FREE, ENHANCED IMMUNOGENICITY VIA INCREASED ANTIGEN CONTENT, FOR INTRAMUSCULAR USE" 90662_3 CDM 636 RC 49281-0121-65 NDC 90662 HCPCS outpatient 240 EA 57 42.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50.73 89 999999999 44.46 54.15 percent of total billed charges "INFLUENZA VIRUS VACCINE (IIV), SPLIT VIRUS, PRESERVATIVE FREE, ENHANCED IMMUNOGENICITY VIA INCREASED ANTIGEN CONTENT, FOR INTRAMUSCULAR USE" 90662_3 CDM 636 RC 49281-0121-65 NDC 90662 HCPCS outpatient 240 EA 57 42.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50.16 88 999999999 44.46 54.15 percent of total billed charges "INFLUENZA VIRUS VACCINE (IIV), SPLIT VIRUS, PRESERVATIVE FREE, ENHANCED IMMUNOGENICITY VIA INCREASED ANTIGEN CONTENT, FOR INTRAMUSCULAR USE" 90662_3 CDM 636 RC 49281-0121-65 NDC 90662 HCPCS outpatient 240 EA 57 42.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50.73 89 999999999 44.46 54.15 percent of total billed charges "PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT (PCV13), FOR INTRAMUSCULAR USE" 90670_3 CDM 636 RC 00005-1971-02 NDC 90670 HCPCS outpatient 1 EA 73 54.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 65.7 90 999999999 56.94 69.35 percent of total billed charges "PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT (PCV13), FOR INTRAMUSCULAR USE" 90670_3 CDM 636 RC 00005-1971-02 NDC 90670 HCPCS outpatient 1 EA 73 54.75 AETNA MCR ADV AETNA MCR ADV 56.94 78 999999999 56.94 69.35 percent of total billed charges "PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT (PCV13), FOR INTRAMUSCULAR USE" 90670_3 CDM 636 RC 00005-1971-02 NDC 90670 HCPCS outpatient 1 EA 73 54.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 63.93 87.57 999999999 56.94 69.35 percent of total billed charges "PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT (PCV13), FOR INTRAMUSCULAR USE" 90670_3 CDM 636 RC 00005-1971-02 NDC 90670 HCPCS outpatient 1 EA 73 54.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 62.1 85.07 999999999 56.94 69.35 percent of total billed charges "PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT (PCV13), FOR INTRAMUSCULAR USE" 90670_3 CDM 636 RC 00005-1971-02 NDC 90670 HCPCS outpatient 1 EA 73 54.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 62.1 85.07 999999999 56.94 69.35 percent of total billed charges "PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT (PCV13), FOR INTRAMUSCULAR USE" 90670_3 CDM 636 RC 00005-1971-02 NDC 90670 HCPCS outpatient 1 EA 73 54.75 MOLINA MCAID MOLINA MCAID 60.88 83.4 999999999 56.94 69.35 percent of total billed charges "PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT (PCV13), FOR INTRAMUSCULAR USE" 90670_3 CDM 636 RC 00005-1971-02 NDC 90670 HCPCS outpatient 1 EA 73 54.75 MOLINA MCR ADV MOLINA MCR ADV 64.97 89 999999999 56.94 69.35 percent of total billed charges "PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT (PCV13), FOR INTRAMUSCULAR USE" 90670_3 CDM 636 RC 00005-1971-02 NDC 90670 HCPCS outpatient 1 EA 73 54.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 64.97 89 999999999 56.94 69.35 percent of total billed charges "PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT (PCV13), FOR INTRAMUSCULAR USE" 90670_3 CDM 636 RC 00005-1971-02 NDC 90670 HCPCS outpatient 1 EA 73 54.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 64.97 89 999999999 56.94 69.35 percent of total billed charges "PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT (PCV13), FOR INTRAMUSCULAR USE" 90670_3 CDM 636 RC 00005-1971-02 NDC 90670 HCPCS outpatient 1 EA 73 54.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 65.7 90 999999999 56.94 69.35 percent of total billed charges "PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT (PCV13), FOR INTRAMUSCULAR USE" 90670_3 CDM 636 RC 00005-1971-02 NDC 90670 HCPCS outpatient 1 EA 73 54.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 69.35 95 999999999 56.94 69.35 percent of total billed charges "PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT (PCV13), FOR INTRAMUSCULAR USE" 90670_3 CDM 636 RC 00005-1971-02 NDC 90670 HCPCS outpatient 1 EA 73 54.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 69.35 95 999999999 56.94 69.35 percent of total billed charges "PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT (PCV13), FOR INTRAMUSCULAR USE" 90670_3 CDM 636 RC 00005-1971-02 NDC 90670 HCPCS outpatient 1 EA 73 54.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 64.97 89 999999999 56.94 69.35 percent of total billed charges "PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT (PCV13), FOR INTRAMUSCULAR USE" 90670_3 CDM 636 RC 00005-1971-02 NDC 90670 HCPCS outpatient 1 EA 73 54.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 64.24 88 999999999 56.94 69.35 percent of total billed charges "PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT (PCV13), FOR INTRAMUSCULAR USE" 90670_3 CDM 636 RC 00005-1971-02 NDC 90670 HCPCS outpatient 1 EA 73 54.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 64.97 89 999999999 56.94 69.35 percent of total billed charges "PNEUMOCOCCAL CONJUGATE VACCINE, 20 VALENT (PCV20), FOR INTRAMUSCULAR USE" 90677_3 CDM 960 RC 90677 HCPCS outpatient 358 268.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 312.9 999999999 312.9 375.9 fee schedule "PNEUMOCOCCAL CONJUGATE VACCINE, 20 VALENT (PCV20), FOR INTRAMUSCULAR USE" 90677_3 CDM 960 RC 90677 HCPCS outpatient 358 268.5 AETNA MCR ADV AETNA MCR ADV 358 999999999 312.9 375.9 fee schedule "PNEUMOCOCCAL CONJUGATE VACCINE, 20 VALENT (PCV20), FOR INTRAMUSCULAR USE" 90677_3 CDM 960 RC 90677 HCPCS outpatient 358 268.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 375.9 999999999 312.9 375.9 fee schedule "PNEUMOCOCCAL CONJUGATE VACCINE, 20 VALENT (PCV20), FOR INTRAMUSCULAR USE" 90677_3 CDM 960 RC 90677 HCPCS outpatient 358 268.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 358 999999999 312.9 375.9 fee schedule "PNEUMOCOCCAL CONJUGATE VACCINE, 20 VALENT (PCV20), FOR INTRAMUSCULAR USE" 90677_3 CDM 960 RC 90677 HCPCS outpatient 358 268.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 358 999999999 312.9 375.9 fee schedule "PNEUMOCOCCAL CONJUGATE VACCINE, 20 VALENT (PCV20), FOR INTRAMUSCULAR USE" 90677_3 CDM 960 RC 90677 HCPCS outpatient 358 268.5 MOLINA MCAID MOLINA MCAID 375.9 999999999 312.9 375.9 fee schedule "PNEUMOCOCCAL CONJUGATE VACCINE, 20 VALENT (PCV20), FOR INTRAMUSCULAR USE" 90677_3 CDM 960 RC 90677 HCPCS outpatient 358 268.5 MOLINA MCR ADV MOLINA MCR ADV 358 999999999 312.9 375.9 fee schedule "PNEUMOCOCCAL CONJUGATE VACCINE, 20 VALENT (PCV20), FOR INTRAMUSCULAR USE" 90677_3 CDM 960 RC 90677 HCPCS outpatient 358 268.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 358 999999999 312.9 375.9 fee schedule "PNEUMOCOCCAL CONJUGATE VACCINE, 20 VALENT (PCV20), FOR INTRAMUSCULAR USE" 90677_3 CDM 960 RC 90677 HCPCS outpatient 358 268.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 358 999999999 312.9 375.9 fee schedule "PNEUMOCOCCAL CONJUGATE VACCINE, 20 VALENT (PCV20), FOR INTRAMUSCULAR USE" 90677_3 CDM 960 RC 90677 HCPCS outpatient 358 268.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 328.62 999999999 312.9 375.9 fee schedule "PNEUMOCOCCAL CONJUGATE VACCINE, 20 VALENT (PCV20), FOR INTRAMUSCULAR USE" 90677_3 CDM 960 RC 90677 HCPCS outpatient 358 268.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 999999999 312.9 375.9 fee schedule "PNEUMOCOCCAL CONJUGATE VACCINE, 20 VALENT (PCV20), FOR INTRAMUSCULAR USE" 90677_3 CDM 960 RC 90677 HCPCS outpatient 358 268.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 999999999 312.9 375.9 fee schedule "PNEUMOCOCCAL CONJUGATE VACCINE, 20 VALENT (PCV20), FOR INTRAMUSCULAR USE" 90677_3 CDM 960 RC 90677 HCPCS outpatient 358 268.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 358 999999999 312.9 375.9 fee schedule "PNEUMOCOCCAL CONJUGATE VACCINE, 20 VALENT (PCV20), FOR INTRAMUSCULAR USE" 90677_3 CDM 960 RC 90677 HCPCS outpatient 358 268.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 313.77 999999999 312.9 375.9 fee schedule "PNEUMOCOCCAL CONJUGATE VACCINE, 20 VALENT (PCV20), FOR INTRAMUSCULAR USE" 90677_3 CDM 960 RC 90677 HCPCS outpatient 358 268.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 358 999999999 312.9 375.9 fee schedule "ROTAVIRUS VACCINE, PENTAVALENT (RV5), 3 DOSE SCHEDULE, LIVE, FOR ORAL USE" 90680_3 CDM 250 RC 00006-4047-41 NDC 90680 HCPCS outpatient 2 EA 20 15 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 18 90 999999999 15.6 19 percent of total billed charges "ROTAVIRUS VACCINE, PENTAVALENT (RV5), 3 DOSE SCHEDULE, LIVE, FOR ORAL USE" 90680_3 CDM 250 RC 00006-4047-41 NDC 90680 HCPCS outpatient 2 EA 20 15 AETNA MCR ADV AETNA MCR ADV 15.6 78 999999999 15.6 19 percent of total billed charges "ROTAVIRUS VACCINE, PENTAVALENT (RV5), 3 DOSE SCHEDULE, LIVE, FOR ORAL USE" 90680_3 CDM 250 RC 00006-4047-41 NDC 90680 HCPCS outpatient 2 EA 20 15 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 17.51 87.57 999999999 15.6 19 percent of total billed charges "ROTAVIRUS VACCINE, PENTAVALENT (RV5), 3 DOSE SCHEDULE, LIVE, FOR ORAL USE" 90680_3 CDM 250 RC 00006-4047-41 NDC 90680 HCPCS outpatient 2 EA 20 15 COORDINATED CARE MCAID COORDINATED CARE MCAID 17.01 85.07 999999999 15.6 19 percent of total billed charges "ROTAVIRUS VACCINE, PENTAVALENT (RV5), 3 DOSE SCHEDULE, LIVE, FOR ORAL USE" 90680_3 CDM 250 RC 00006-4047-41 NDC 90680 HCPCS outpatient 2 EA 20 15 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 17.01 85.07 999999999 15.6 19 percent of total billed charges "ROTAVIRUS VACCINE, PENTAVALENT (RV5), 3 DOSE SCHEDULE, LIVE, FOR ORAL USE" 90680_3 CDM 250 RC 00006-4047-41 NDC 90680 HCPCS outpatient 2 EA 20 15 MOLINA MCAID MOLINA MCAID 16.68 83.4 999999999 15.6 19 percent of total billed charges "ROTAVIRUS VACCINE, PENTAVALENT (RV5), 3 DOSE SCHEDULE, LIVE, FOR ORAL USE" 90680_3 CDM 250 RC 00006-4047-41 NDC 90680 HCPCS outpatient 2 EA 20 15 MOLINA MCR ADV MOLINA MCR ADV 17.8 89 999999999 15.6 19 percent of total billed charges "ROTAVIRUS VACCINE, PENTAVALENT (RV5), 3 DOSE SCHEDULE, LIVE, FOR ORAL USE" 90680_3 CDM 250 RC 00006-4047-41 NDC 90680 HCPCS outpatient 2 EA 20 15 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "ROTAVIRUS VACCINE, PENTAVALENT (RV5), 3 DOSE SCHEDULE, LIVE, FOR ORAL USE" 90680_3 CDM 250 RC 00006-4047-41 NDC 90680 HCPCS outpatient 2 EA 20 15 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "ROTAVIRUS VACCINE, PENTAVALENT (RV5), 3 DOSE SCHEDULE, LIVE, FOR ORAL USE" 90680_3 CDM 250 RC 00006-4047-41 NDC 90680 HCPCS outpatient 2 EA 20 15 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 18 90 999999999 15.6 19 percent of total billed charges "ROTAVIRUS VACCINE, PENTAVALENT (RV5), 3 DOSE SCHEDULE, LIVE, FOR ORAL USE" 90680_3 CDM 250 RC 00006-4047-41 NDC 90680 HCPCS outpatient 2 EA 20 15 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 19 95 999999999 15.6 19 percent of total billed charges "ROTAVIRUS VACCINE, PENTAVALENT (RV5), 3 DOSE SCHEDULE, LIVE, FOR ORAL USE" 90680_3 CDM 250 RC 00006-4047-41 NDC 90680 HCPCS outpatient 2 EA 20 15 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 19 95 999999999 15.6 19 percent of total billed charges "ROTAVIRUS VACCINE, PENTAVALENT (RV5), 3 DOSE SCHEDULE, LIVE, FOR ORAL USE" 90680_3 CDM 250 RC 00006-4047-41 NDC 90680 HCPCS outpatient 2 EA 20 15 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 17.8 89 999999999 15.6 19 percent of total billed charges "ROTAVIRUS VACCINE, PENTAVALENT (RV5), 3 DOSE SCHEDULE, LIVE, FOR ORAL USE" 90680_3 CDM 250 RC 00006-4047-41 NDC 90680 HCPCS outpatient 2 EA 20 15 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 17.6 88 999999999 15.6 19 percent of total billed charges "ROTAVIRUS VACCINE, PENTAVALENT (RV5), 3 DOSE SCHEDULE, LIVE, FOR ORAL USE" 90680_3 CDM 250 RC 00006-4047-41 NDC 90680 HCPCS outpatient 2 EA 20 15 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "ROTAVIRUS VACCINE, HUMAN, ATTENUATED (RV1), 2 DOSE SCHEDULE, LIVE, FOR ORAL USE" 90681_3 CDM 250 RC 90681 HCPCS outpatient 20 15 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 18 90 999999999 15.6 19 percent of total billed charges "ROTAVIRUS VACCINE, HUMAN, ATTENUATED (RV1), 2 DOSE SCHEDULE, LIVE, FOR ORAL USE" 90681_3 CDM 250 RC 90681 HCPCS outpatient 20 15 AETNA MCR ADV AETNA MCR ADV 15.6 78 999999999 15.6 19 percent of total billed charges "ROTAVIRUS VACCINE, HUMAN, ATTENUATED (RV1), 2 DOSE SCHEDULE, LIVE, FOR ORAL USE" 90681_3 CDM 250 RC 90681 HCPCS outpatient 20 15 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 17.51 87.57 999999999 15.6 19 percent of total billed charges "ROTAVIRUS VACCINE, HUMAN, ATTENUATED (RV1), 2 DOSE SCHEDULE, LIVE, FOR ORAL USE" 90681_3 CDM 250 RC 90681 HCPCS outpatient 20 15 COORDINATED CARE MCAID COORDINATED CARE MCAID 17.01 85.07 999999999 15.6 19 percent of total billed charges "ROTAVIRUS VACCINE, HUMAN, ATTENUATED (RV1), 2 DOSE SCHEDULE, LIVE, FOR ORAL USE" 90681_3 CDM 250 RC 90681 HCPCS outpatient 20 15 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 17.01 85.07 999999999 15.6 19 percent of total billed charges "ROTAVIRUS VACCINE, HUMAN, ATTENUATED (RV1), 2 DOSE SCHEDULE, LIVE, FOR ORAL USE" 90681_3 CDM 250 RC 90681 HCPCS outpatient 20 15 MOLINA MCAID MOLINA MCAID 16.68 83.4 999999999 15.6 19 percent of total billed charges "ROTAVIRUS VACCINE, HUMAN, ATTENUATED (RV1), 2 DOSE SCHEDULE, LIVE, FOR ORAL USE" 90681_3 CDM 250 RC 90681 HCPCS outpatient 20 15 MOLINA MCR ADV MOLINA MCR ADV 17.8 89 999999999 15.6 19 percent of total billed charges "ROTAVIRUS VACCINE, HUMAN, ATTENUATED (RV1), 2 DOSE SCHEDULE, LIVE, FOR ORAL USE" 90681_3 CDM 250 RC 90681 HCPCS outpatient 20 15 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "ROTAVIRUS VACCINE, HUMAN, ATTENUATED (RV1), 2 DOSE SCHEDULE, LIVE, FOR ORAL USE" 90681_3 CDM 250 RC 90681 HCPCS outpatient 20 15 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "ROTAVIRUS VACCINE, HUMAN, ATTENUATED (RV1), 2 DOSE SCHEDULE, LIVE, FOR ORAL USE" 90681_3 CDM 250 RC 90681 HCPCS outpatient 20 15 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 18 90 999999999 15.6 19 percent of total billed charges "ROTAVIRUS VACCINE, HUMAN, ATTENUATED (RV1), 2 DOSE SCHEDULE, LIVE, FOR ORAL USE" 90681_3 CDM 250 RC 90681 HCPCS outpatient 20 15 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 19 95 999999999 15.6 19 percent of total billed charges "ROTAVIRUS VACCINE, HUMAN, ATTENUATED (RV1), 2 DOSE SCHEDULE, LIVE, FOR ORAL USE" 90681_3 CDM 250 RC 90681 HCPCS outpatient 20 15 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 19 95 999999999 15.6 19 percent of total billed charges "ROTAVIRUS VACCINE, HUMAN, ATTENUATED (RV1), 2 DOSE SCHEDULE, LIVE, FOR ORAL USE" 90681_3 CDM 250 RC 90681 HCPCS outpatient 20 15 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 17.8 89 999999999 15.6 19 percent of total billed charges "ROTAVIRUS VACCINE, HUMAN, ATTENUATED (RV1), 2 DOSE SCHEDULE, LIVE, FOR ORAL USE" 90681_3 CDM 250 RC 90681 HCPCS outpatient 20 15 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 17.6 88 999999999 15.6 19 percent of total billed charges "ROTAVIRUS VACCINE, HUMAN, ATTENUATED (RV1), 2 DOSE SCHEDULE, LIVE, FOR ORAL USE" 90681_3 CDM 250 RC 90681 HCPCS outpatient 20 15 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 90688_3 CDM 960 RC 90688 HCPCS outpatient 26 19.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 18.68 999999999 18.68 27.3 fee schedule "INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 90688_3 CDM 960 RC 90688 HCPCS outpatient 26 19.5 AETNA MCR ADV AETNA MCR ADV 26 999999999 18.68 27.3 fee schedule "INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 90688_3 CDM 960 RC 90688 HCPCS outpatient 26 19.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 27.3 999999999 18.68 27.3 fee schedule "INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 90688_3 CDM 960 RC 90688 HCPCS outpatient 26 19.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 26 999999999 18.68 27.3 fee schedule "INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 90688_3 CDM 960 RC 90688 HCPCS outpatient 26 19.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 26 999999999 18.68 27.3 fee schedule "INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 90688_3 CDM 960 RC 90688 HCPCS outpatient 26 19.5 MOLINA MCAID MOLINA MCAID 27.3 999999999 18.68 27.3 fee schedule "INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 90688_3 CDM 960 RC 90688 HCPCS outpatient 26 19.5 MOLINA MCR ADV MOLINA MCR ADV 26 999999999 18.68 27.3 fee schedule "INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 90688_3 CDM 960 RC 90688 HCPCS outpatient 26 19.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 26 999999999 18.68 27.3 fee schedule "INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 90688_3 CDM 960 RC 90688 HCPCS outpatient 26 19.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 26 999999999 18.68 27.3 fee schedule "INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 90688_3 CDM 960 RC 90688 HCPCS outpatient 26 19.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 26.38 999999999 18.68 27.3 fee schedule "INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 90688_3 CDM 960 RC 90688 HCPCS outpatient 26 19.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 999999999 18.68 27.3 "INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 90688_3 CDM 960 RC 90688 HCPCS outpatient 26 19.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 999999999 18.68 27.3 "INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 90688_3 CDM 960 RC 90688 HCPCS outpatient 26 19.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 26 999999999 18.68 27.3 fee schedule "INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 90688_3 CDM 960 RC 90688 HCPCS outpatient 26 19.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 21.98 999999999 18.68 27.3 fee schedule "INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 90688_3 CDM 960 RC 90688 HCPCS outpatient 26 19.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 26 999999999 18.68 27.3 fee schedule "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE AND INACTIVATED POLIOVIRUS VACCINE (DTAP-IPV), WHEN ADMINISTERED TO CHILDREN 4 THROUGH 6 YEARS OF AGE, FOR INTRAMUSCULAR USE" 90696_3 CDM 250 RC 58160-0812-11 NDC 90696 HCPCS outpatient 1 EA 20 15 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 18 90 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE AND INACTIVATED POLIOVIRUS VACCINE (DTAP-IPV), WHEN ADMINISTERED TO CHILDREN 4 THROUGH 6 YEARS OF AGE, FOR INTRAMUSCULAR USE" 90696_3 CDM 250 RC 58160-0812-11 NDC 90696 HCPCS outpatient 1 EA 20 15 AETNA MCR ADV AETNA MCR ADV 15.6 78 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE AND INACTIVATED POLIOVIRUS VACCINE (DTAP-IPV), WHEN ADMINISTERED TO CHILDREN 4 THROUGH 6 YEARS OF AGE, FOR INTRAMUSCULAR USE" 90696_3 CDM 250 RC 58160-0812-11 NDC 90696 HCPCS outpatient 1 EA 20 15 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 17.51 87.57 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE AND INACTIVATED POLIOVIRUS VACCINE (DTAP-IPV), WHEN ADMINISTERED TO CHILDREN 4 THROUGH 6 YEARS OF AGE, FOR INTRAMUSCULAR USE" 90696_3 CDM 250 RC 58160-0812-11 NDC 90696 HCPCS outpatient 1 EA 20 15 COORDINATED CARE MCAID COORDINATED CARE MCAID 17.01 85.07 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE AND INACTIVATED POLIOVIRUS VACCINE (DTAP-IPV), WHEN ADMINISTERED TO CHILDREN 4 THROUGH 6 YEARS OF AGE, FOR INTRAMUSCULAR USE" 90696_3 CDM 250 RC 58160-0812-11 NDC 90696 HCPCS outpatient 1 EA 20 15 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 17.01 85.07 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE AND INACTIVATED POLIOVIRUS VACCINE (DTAP-IPV), WHEN ADMINISTERED TO CHILDREN 4 THROUGH 6 YEARS OF AGE, FOR INTRAMUSCULAR USE" 90696_3 CDM 250 RC 58160-0812-11 NDC 90696 HCPCS outpatient 1 EA 20 15 MOLINA MCAID MOLINA MCAID 16.68 83.4 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE AND INACTIVATED POLIOVIRUS VACCINE (DTAP-IPV), WHEN ADMINISTERED TO CHILDREN 4 THROUGH 6 YEARS OF AGE, FOR INTRAMUSCULAR USE" 90696_3 CDM 250 RC 58160-0812-11 NDC 90696 HCPCS outpatient 1 EA 20 15 MOLINA MCR ADV MOLINA MCR ADV 17.8 89 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE AND INACTIVATED POLIOVIRUS VACCINE (DTAP-IPV), WHEN ADMINISTERED TO CHILDREN 4 THROUGH 6 YEARS OF AGE, FOR INTRAMUSCULAR USE" 90696_3 CDM 250 RC 58160-0812-11 NDC 90696 HCPCS outpatient 1 EA 20 15 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE AND INACTIVATED POLIOVIRUS VACCINE (DTAP-IPV), WHEN ADMINISTERED TO CHILDREN 4 THROUGH 6 YEARS OF AGE, FOR INTRAMUSCULAR USE" 90696_3 CDM 250 RC 58160-0812-11 NDC 90696 HCPCS outpatient 1 EA 20 15 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE AND INACTIVATED POLIOVIRUS VACCINE (DTAP-IPV), WHEN ADMINISTERED TO CHILDREN 4 THROUGH 6 YEARS OF AGE, FOR INTRAMUSCULAR USE" 90696_3 CDM 250 RC 58160-0812-11 NDC 90696 HCPCS outpatient 1 EA 20 15 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 18 90 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE AND INACTIVATED POLIOVIRUS VACCINE (DTAP-IPV), WHEN ADMINISTERED TO CHILDREN 4 THROUGH 6 YEARS OF AGE, FOR INTRAMUSCULAR USE" 90696_3 CDM 250 RC 58160-0812-11 NDC 90696 HCPCS outpatient 1 EA 20 15 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 19 95 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE AND INACTIVATED POLIOVIRUS VACCINE (DTAP-IPV), WHEN ADMINISTERED TO CHILDREN 4 THROUGH 6 YEARS OF AGE, FOR INTRAMUSCULAR USE" 90696_3 CDM 250 RC 58160-0812-11 NDC 90696 HCPCS outpatient 1 EA 20 15 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 19 95 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE AND INACTIVATED POLIOVIRUS VACCINE (DTAP-IPV), WHEN ADMINISTERED TO CHILDREN 4 THROUGH 6 YEARS OF AGE, FOR INTRAMUSCULAR USE" 90696_3 CDM 250 RC 58160-0812-11 NDC 90696 HCPCS outpatient 1 EA 20 15 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 17.8 89 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE AND INACTIVATED POLIOVIRUS VACCINE (DTAP-IPV), WHEN ADMINISTERED TO CHILDREN 4 THROUGH 6 YEARS OF AGE, FOR INTRAMUSCULAR USE" 90696_3 CDM 250 RC 58160-0812-11 NDC 90696 HCPCS outpatient 1 EA 20 15 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 17.6 88 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE AND INACTIVATED POLIOVIRUS VACCINE (DTAP-IPV), WHEN ADMINISTERED TO CHILDREN 4 THROUGH 6 YEARS OF AGE, FOR INTRAMUSCULAR USE" 90696_3 CDM 250 RC 58160-0812-11 NDC 90696 HCPCS outpatient 1 EA 20 15 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, HAEMOPHILUS INFLUENZAE TYPE B, AND INACTIVATED POLIOVIRUS VACCINE, (DTAP-IPV/HIB), FOR INTRAMUSCULAR USE" 90698_3 CDM 636 RC 49281-0510-05 NDC 90698 HCPCS outpatient 1 EA 20 15 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 18 90 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, HAEMOPHILUS INFLUENZAE TYPE B, AND INACTIVATED POLIOVIRUS VACCINE, (DTAP-IPV/HIB), FOR INTRAMUSCULAR USE" 90698_3 CDM 636 RC 49281-0510-05 NDC 90698 HCPCS outpatient 1 EA 20 15 AETNA MCR ADV AETNA MCR ADV 15.6 78 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, HAEMOPHILUS INFLUENZAE TYPE B, AND INACTIVATED POLIOVIRUS VACCINE, (DTAP-IPV/HIB), FOR INTRAMUSCULAR USE" 90698_3 CDM 636 RC 49281-0510-05 NDC 90698 HCPCS outpatient 1 EA 20 15 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 17.51 87.57 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, HAEMOPHILUS INFLUENZAE TYPE B, AND INACTIVATED POLIOVIRUS VACCINE, (DTAP-IPV/HIB), FOR INTRAMUSCULAR USE" 90698_3 CDM 636 RC 49281-0510-05 NDC 90698 HCPCS outpatient 1 EA 20 15 COORDINATED CARE MCAID COORDINATED CARE MCAID 17.01 85.07 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, HAEMOPHILUS INFLUENZAE TYPE B, AND INACTIVATED POLIOVIRUS VACCINE, (DTAP-IPV/HIB), FOR INTRAMUSCULAR USE" 90698_3 CDM 636 RC 49281-0510-05 NDC 90698 HCPCS outpatient 1 EA 20 15 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 17.01 85.07 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, HAEMOPHILUS INFLUENZAE TYPE B, AND INACTIVATED POLIOVIRUS VACCINE, (DTAP-IPV/HIB), FOR INTRAMUSCULAR USE" 90698_3 CDM 636 RC 49281-0510-05 NDC 90698 HCPCS outpatient 1 EA 20 15 MOLINA MCAID MOLINA MCAID 16.68 83.4 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, HAEMOPHILUS INFLUENZAE TYPE B, AND INACTIVATED POLIOVIRUS VACCINE, (DTAP-IPV/HIB), FOR INTRAMUSCULAR USE" 90698_3 CDM 636 RC 49281-0510-05 NDC 90698 HCPCS outpatient 1 EA 20 15 MOLINA MCR ADV MOLINA MCR ADV 17.8 89 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, HAEMOPHILUS INFLUENZAE TYPE B, AND INACTIVATED POLIOVIRUS VACCINE, (DTAP-IPV/HIB), FOR INTRAMUSCULAR USE" 90698_3 CDM 636 RC 49281-0510-05 NDC 90698 HCPCS outpatient 1 EA 20 15 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, HAEMOPHILUS INFLUENZAE TYPE B, AND INACTIVATED POLIOVIRUS VACCINE, (DTAP-IPV/HIB), FOR INTRAMUSCULAR USE" 90698_3 CDM 636 RC 49281-0510-05 NDC 90698 HCPCS outpatient 1 EA 20 15 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, HAEMOPHILUS INFLUENZAE TYPE B, AND INACTIVATED POLIOVIRUS VACCINE, (DTAP-IPV/HIB), FOR INTRAMUSCULAR USE" 90698_3 CDM 636 RC 49281-0510-05 NDC 90698 HCPCS outpatient 1 EA 20 15 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 18 90 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, HAEMOPHILUS INFLUENZAE TYPE B, AND INACTIVATED POLIOVIRUS VACCINE, (DTAP-IPV/HIB), FOR INTRAMUSCULAR USE" 90698_3 CDM 636 RC 49281-0510-05 NDC 90698 HCPCS outpatient 1 EA 20 15 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 19 95 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, HAEMOPHILUS INFLUENZAE TYPE B, AND INACTIVATED POLIOVIRUS VACCINE, (DTAP-IPV/HIB), FOR INTRAMUSCULAR USE" 90698_3 CDM 636 RC 49281-0510-05 NDC 90698 HCPCS outpatient 1 EA 20 15 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 19 95 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, HAEMOPHILUS INFLUENZAE TYPE B, AND INACTIVATED POLIOVIRUS VACCINE, (DTAP-IPV/HIB), FOR INTRAMUSCULAR USE" 90698_3 CDM 636 RC 49281-0510-05 NDC 90698 HCPCS outpatient 1 EA 20 15 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 17.8 89 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, HAEMOPHILUS INFLUENZAE TYPE B, AND INACTIVATED POLIOVIRUS VACCINE, (DTAP-IPV/HIB), FOR INTRAMUSCULAR USE" 90698_3 CDM 636 RC 49281-0510-05 NDC 90698 HCPCS outpatient 1 EA 20 15 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 17.6 88 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, HAEMOPHILUS INFLUENZAE TYPE B, AND INACTIVATED POLIOVIRUS VACCINE, (DTAP-IPV/HIB), FOR INTRAMUSCULAR USE" 90698_3 CDM 636 RC 49281-0510-05 NDC 90698 HCPCS outpatient 1 EA 20 15 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, AND ACELLULAR PERTUSSIS VACCINE (DTAP), WHEN ADMINISTERED TO INDIVIDUALS YOUNGER THAN 7 YEARS, FOR INTRAMUSCULAR USE" 90700_3 CDM 250 RC 49281-0286-10 NDC 90700 HCPCS outpatient 1 EA 20 15 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 18 90 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, AND ACELLULAR PERTUSSIS VACCINE (DTAP), WHEN ADMINISTERED TO INDIVIDUALS YOUNGER THAN 7 YEARS, FOR INTRAMUSCULAR USE" 90700_3 CDM 250 RC 49281-0286-10 NDC 90700 HCPCS outpatient 1 EA 20 15 AETNA MCR ADV AETNA MCR ADV 15.6 78 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, AND ACELLULAR PERTUSSIS VACCINE (DTAP), WHEN ADMINISTERED TO INDIVIDUALS YOUNGER THAN 7 YEARS, FOR INTRAMUSCULAR USE" 90700_3 CDM 250 RC 49281-0286-10 NDC 90700 HCPCS outpatient 1 EA 20 15 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 17.51 87.57 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, AND ACELLULAR PERTUSSIS VACCINE (DTAP), WHEN ADMINISTERED TO INDIVIDUALS YOUNGER THAN 7 YEARS, FOR INTRAMUSCULAR USE" 90700_3 CDM 250 RC 49281-0286-10 NDC 90700 HCPCS outpatient 1 EA 20 15 COORDINATED CARE MCAID COORDINATED CARE MCAID 17.01 85.07 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, AND ACELLULAR PERTUSSIS VACCINE (DTAP), WHEN ADMINISTERED TO INDIVIDUALS YOUNGER THAN 7 YEARS, FOR INTRAMUSCULAR USE" 90700_3 CDM 250 RC 49281-0286-10 NDC 90700 HCPCS outpatient 1 EA 20 15 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 17.01 85.07 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, AND ACELLULAR PERTUSSIS VACCINE (DTAP), WHEN ADMINISTERED TO INDIVIDUALS YOUNGER THAN 7 YEARS, FOR INTRAMUSCULAR USE" 90700_3 CDM 250 RC 49281-0286-10 NDC 90700 HCPCS outpatient 1 EA 20 15 MOLINA MCAID MOLINA MCAID 16.68 83.4 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, AND ACELLULAR PERTUSSIS VACCINE (DTAP), WHEN ADMINISTERED TO INDIVIDUALS YOUNGER THAN 7 YEARS, FOR INTRAMUSCULAR USE" 90700_3 CDM 250 RC 49281-0286-10 NDC 90700 HCPCS outpatient 1 EA 20 15 MOLINA MCR ADV MOLINA MCR ADV 17.8 89 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, AND ACELLULAR PERTUSSIS VACCINE (DTAP), WHEN ADMINISTERED TO INDIVIDUALS YOUNGER THAN 7 YEARS, FOR INTRAMUSCULAR USE" 90700_3 CDM 250 RC 49281-0286-10 NDC 90700 HCPCS outpatient 1 EA 20 15 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, AND ACELLULAR PERTUSSIS VACCINE (DTAP), WHEN ADMINISTERED TO INDIVIDUALS YOUNGER THAN 7 YEARS, FOR INTRAMUSCULAR USE" 90700_3 CDM 250 RC 49281-0286-10 NDC 90700 HCPCS outpatient 1 EA 20 15 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, AND ACELLULAR PERTUSSIS VACCINE (DTAP), WHEN ADMINISTERED TO INDIVIDUALS YOUNGER THAN 7 YEARS, FOR INTRAMUSCULAR USE" 90700_3 CDM 250 RC 49281-0286-10 NDC 90700 HCPCS outpatient 1 EA 20 15 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 18 90 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, AND ACELLULAR PERTUSSIS VACCINE (DTAP), WHEN ADMINISTERED TO INDIVIDUALS YOUNGER THAN 7 YEARS, FOR INTRAMUSCULAR USE" 90700_3 CDM 250 RC 49281-0286-10 NDC 90700 HCPCS outpatient 1 EA 20 15 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 19 95 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, AND ACELLULAR PERTUSSIS VACCINE (DTAP), WHEN ADMINISTERED TO INDIVIDUALS YOUNGER THAN 7 YEARS, FOR INTRAMUSCULAR USE" 90700_3 CDM 250 RC 49281-0286-10 NDC 90700 HCPCS outpatient 1 EA 20 15 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 19 95 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, AND ACELLULAR PERTUSSIS VACCINE (DTAP), WHEN ADMINISTERED TO INDIVIDUALS YOUNGER THAN 7 YEARS, FOR INTRAMUSCULAR USE" 90700_3 CDM 250 RC 49281-0286-10 NDC 90700 HCPCS outpatient 1 EA 20 15 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 17.8 89 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, AND ACELLULAR PERTUSSIS VACCINE (DTAP), WHEN ADMINISTERED TO INDIVIDUALS YOUNGER THAN 7 YEARS, FOR INTRAMUSCULAR USE" 90700_3 CDM 250 RC 49281-0286-10 NDC 90700 HCPCS outpatient 1 EA 20 15 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 17.6 88 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, AND ACELLULAR PERTUSSIS VACCINE (DTAP), WHEN ADMINISTERED TO INDIVIDUALS YOUNGER THAN 7 YEARS, FOR INTRAMUSCULAR USE" 90700_3 CDM 250 RC 49281-0286-10 NDC 90700 HCPCS outpatient 1 EA 20 15 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "MEASLES, MUMPS AND RUBELLA VIRUS VACCINE (MMR), LIVE, FOR SUBCUTANEOUS USE" 90707_3 CDM 636 RC 00006-4171-01 NDC 90707 HCPCS outpatient 1 EA 20 15 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 18 90 999999999 15.6 19 percent of total billed charges "MEASLES, MUMPS AND RUBELLA VIRUS VACCINE (MMR), LIVE, FOR SUBCUTANEOUS USE" 90707_3 CDM 636 RC 00006-4171-01 NDC 90707 HCPCS outpatient 1 EA 20 15 AETNA MCR ADV AETNA MCR ADV 15.6 78 999999999 15.6 19 percent of total billed charges "MEASLES, MUMPS AND RUBELLA VIRUS VACCINE (MMR), LIVE, FOR SUBCUTANEOUS USE" 90707_3 CDM 636 RC 00006-4171-01 NDC 90707 HCPCS outpatient 1 EA 20 15 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 17.51 87.57 999999999 15.6 19 percent of total billed charges "MEASLES, MUMPS AND RUBELLA VIRUS VACCINE (MMR), LIVE, FOR SUBCUTANEOUS USE" 90707_3 CDM 636 RC 00006-4171-01 NDC 90707 HCPCS outpatient 1 EA 20 15 COORDINATED CARE MCAID COORDINATED CARE MCAID 17.01 85.07 999999999 15.6 19 percent of total billed charges "MEASLES, MUMPS AND RUBELLA VIRUS VACCINE (MMR), LIVE, FOR SUBCUTANEOUS USE" 90707_3 CDM 636 RC 00006-4171-01 NDC 90707 HCPCS outpatient 1 EA 20 15 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 17.01 85.07 999999999 15.6 19 percent of total billed charges "MEASLES, MUMPS AND RUBELLA VIRUS VACCINE (MMR), LIVE, FOR SUBCUTANEOUS USE" 90707_3 CDM 636 RC 00006-4171-01 NDC 90707 HCPCS outpatient 1 EA 20 15 MOLINA MCAID MOLINA MCAID 16.68 83.4 999999999 15.6 19 percent of total billed charges "MEASLES, MUMPS AND RUBELLA VIRUS VACCINE (MMR), LIVE, FOR SUBCUTANEOUS USE" 90707_3 CDM 636 RC 00006-4171-01 NDC 90707 HCPCS outpatient 1 EA 20 15 MOLINA MCR ADV MOLINA MCR ADV 17.8 89 999999999 15.6 19 percent of total billed charges "MEASLES, MUMPS AND RUBELLA VIRUS VACCINE (MMR), LIVE, FOR SUBCUTANEOUS USE" 90707_3 CDM 636 RC 00006-4171-01 NDC 90707 HCPCS outpatient 1 EA 20 15 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "MEASLES, MUMPS AND RUBELLA VIRUS VACCINE (MMR), LIVE, FOR SUBCUTANEOUS USE" 90707_3 CDM 636 RC 00006-4171-01 NDC 90707 HCPCS outpatient 1 EA 20 15 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "MEASLES, MUMPS AND RUBELLA VIRUS VACCINE (MMR), LIVE, FOR SUBCUTANEOUS USE" 90707_3 CDM 636 RC 00006-4171-01 NDC 90707 HCPCS outpatient 1 EA 20 15 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 18 90 999999999 15.6 19 percent of total billed charges "MEASLES, MUMPS AND RUBELLA VIRUS VACCINE (MMR), LIVE, FOR SUBCUTANEOUS USE" 90707_3 CDM 636 RC 00006-4171-01 NDC 90707 HCPCS outpatient 1 EA 20 15 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 19 95 999999999 15.6 19 percent of total billed charges "MEASLES, MUMPS AND RUBELLA VIRUS VACCINE (MMR), LIVE, FOR SUBCUTANEOUS USE" 90707_3 CDM 636 RC 00006-4171-01 NDC 90707 HCPCS outpatient 1 EA 20 15 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 19 95 999999999 15.6 19 percent of total billed charges "MEASLES, MUMPS AND RUBELLA VIRUS VACCINE (MMR), LIVE, FOR SUBCUTANEOUS USE" 90707_3 CDM 636 RC 00006-4171-01 NDC 90707 HCPCS outpatient 1 EA 20 15 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 17.8 89 999999999 15.6 19 percent of total billed charges "MEASLES, MUMPS AND RUBELLA VIRUS VACCINE (MMR), LIVE, FOR SUBCUTANEOUS USE" 90707_3 CDM 636 RC 00006-4171-01 NDC 90707 HCPCS outpatient 1 EA 20 15 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 17.6 88 999999999 15.6 19 percent of total billed charges "MEASLES, MUMPS AND RUBELLA VIRUS VACCINE (MMR), LIVE, FOR SUBCUTANEOUS USE" 90707_3 CDM 636 RC 00006-4171-01 NDC 90707 HCPCS outpatient 1 EA 20 15 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "MEASLES, MUMPS, RUBELLA, AND VARICELLA VACCINE (MMRV), LIVE, FOR SUBCUTANEOUS USE" 90710_3 CDM 636 RC 00006-4171-01 NDC 90710 HCPCS outpatient 1 EA 20 15 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 18 90 999999999 15.6 19 percent of total billed charges "MEASLES, MUMPS, RUBELLA, AND VARICELLA VACCINE (MMRV), LIVE, FOR SUBCUTANEOUS USE" 90710_3 CDM 636 RC 00006-4171-01 NDC 90710 HCPCS outpatient 1 EA 20 15 AETNA MCR ADV AETNA MCR ADV 15.6 78 999999999 15.6 19 percent of total billed charges "MEASLES, MUMPS, RUBELLA, AND VARICELLA VACCINE (MMRV), LIVE, FOR SUBCUTANEOUS USE" 90710_3 CDM 636 RC 00006-4171-01 NDC 90710 HCPCS outpatient 1 EA 20 15 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 17.51 87.57 999999999 15.6 19 percent of total billed charges "MEASLES, MUMPS, RUBELLA, AND VARICELLA VACCINE (MMRV), LIVE, FOR SUBCUTANEOUS USE" 90710_3 CDM 636 RC 00006-4171-01 NDC 90710 HCPCS outpatient 1 EA 20 15 COORDINATED CARE MCAID COORDINATED CARE MCAID 17.01 85.07 999999999 15.6 19 percent of total billed charges "MEASLES, MUMPS, RUBELLA, AND VARICELLA VACCINE (MMRV), LIVE, FOR SUBCUTANEOUS USE" 90710_3 CDM 636 RC 00006-4171-01 NDC 90710 HCPCS outpatient 1 EA 20 15 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 17.01 85.07 999999999 15.6 19 percent of total billed charges "MEASLES, MUMPS, RUBELLA, AND VARICELLA VACCINE (MMRV), LIVE, FOR SUBCUTANEOUS USE" 90710_3 CDM 636 RC 00006-4171-01 NDC 90710 HCPCS outpatient 1 EA 20 15 MOLINA MCAID MOLINA MCAID 16.68 83.4 999999999 15.6 19 percent of total billed charges "MEASLES, MUMPS, RUBELLA, AND VARICELLA VACCINE (MMRV), LIVE, FOR SUBCUTANEOUS USE" 90710_3 CDM 636 RC 00006-4171-01 NDC 90710 HCPCS outpatient 1 EA 20 15 MOLINA MCR ADV MOLINA MCR ADV 17.8 89 999999999 15.6 19 percent of total billed charges "MEASLES, MUMPS, RUBELLA, AND VARICELLA VACCINE (MMRV), LIVE, FOR SUBCUTANEOUS USE" 90710_3 CDM 636 RC 00006-4171-01 NDC 90710 HCPCS outpatient 1 EA 20 15 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "MEASLES, MUMPS, RUBELLA, AND VARICELLA VACCINE (MMRV), LIVE, FOR SUBCUTANEOUS USE" 90710_3 CDM 636 RC 00006-4171-01 NDC 90710 HCPCS outpatient 1 EA 20 15 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "MEASLES, MUMPS, RUBELLA, AND VARICELLA VACCINE (MMRV), LIVE, FOR SUBCUTANEOUS USE" 90710_3 CDM 636 RC 00006-4171-01 NDC 90710 HCPCS outpatient 1 EA 20 15 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 18 90 999999999 15.6 19 percent of total billed charges "MEASLES, MUMPS, RUBELLA, AND VARICELLA VACCINE (MMRV), LIVE, FOR SUBCUTANEOUS USE" 90710_3 CDM 636 RC 00006-4171-01 NDC 90710 HCPCS outpatient 1 EA 20 15 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 19 95 999999999 15.6 19 percent of total billed charges "MEASLES, MUMPS, RUBELLA, AND VARICELLA VACCINE (MMRV), LIVE, FOR SUBCUTANEOUS USE" 90710_3 CDM 636 RC 00006-4171-01 NDC 90710 HCPCS outpatient 1 EA 20 15 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 19 95 999999999 15.6 19 percent of total billed charges "MEASLES, MUMPS, RUBELLA, AND VARICELLA VACCINE (MMRV), LIVE, FOR SUBCUTANEOUS USE" 90710_3 CDM 636 RC 00006-4171-01 NDC 90710 HCPCS outpatient 1 EA 20 15 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 17.8 89 999999999 15.6 19 percent of total billed charges "MEASLES, MUMPS, RUBELLA, AND VARICELLA VACCINE (MMRV), LIVE, FOR SUBCUTANEOUS USE" 90710_3 CDM 636 RC 00006-4171-01 NDC 90710 HCPCS outpatient 1 EA 20 15 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 17.6 88 999999999 15.6 19 percent of total billed charges "MEASLES, MUMPS, RUBELLA, AND VARICELLA VACCINE (MMRV), LIVE, FOR SUBCUTANEOUS USE" 90710_3 CDM 636 RC 00006-4171-01 NDC 90710 HCPCS outpatient 1 EA 20 15 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "POLIOVIRUS VACCINE, INACTIVATED (IPV), FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 90713_3 CDM 636 RC 49281-0860-10 NDC 90713 HCPCS outpatient 1 EA 20 15 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 18 90 999999999 15.6 19 percent of total billed charges "POLIOVIRUS VACCINE, INACTIVATED (IPV), FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 90713_3 CDM 636 RC 49281-0860-10 NDC 90713 HCPCS outpatient 1 EA 20 15 AETNA MCR ADV AETNA MCR ADV 15.6 78 999999999 15.6 19 percent of total billed charges "POLIOVIRUS VACCINE, INACTIVATED (IPV), FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 90713_3 CDM 636 RC 49281-0860-10 NDC 90713 HCPCS outpatient 1 EA 20 15 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 17.51 87.57 999999999 15.6 19 percent of total billed charges "POLIOVIRUS VACCINE, INACTIVATED (IPV), FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 90713_3 CDM 636 RC 49281-0860-10 NDC 90713 HCPCS outpatient 1 EA 20 15 COORDINATED CARE MCAID COORDINATED CARE MCAID 17.01 85.07 999999999 15.6 19 percent of total billed charges "POLIOVIRUS VACCINE, INACTIVATED (IPV), FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 90713_3 CDM 636 RC 49281-0860-10 NDC 90713 HCPCS outpatient 1 EA 20 15 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 17.01 85.07 999999999 15.6 19 percent of total billed charges "POLIOVIRUS VACCINE, INACTIVATED (IPV), FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 90713_3 CDM 636 RC 49281-0860-10 NDC 90713 HCPCS outpatient 1 EA 20 15 MOLINA MCAID MOLINA MCAID 16.68 83.4 999999999 15.6 19 percent of total billed charges "POLIOVIRUS VACCINE, INACTIVATED (IPV), FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 90713_3 CDM 636 RC 49281-0860-10 NDC 90713 HCPCS outpatient 1 EA 20 15 MOLINA MCR ADV MOLINA MCR ADV 17.8 89 999999999 15.6 19 percent of total billed charges "POLIOVIRUS VACCINE, INACTIVATED (IPV), FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 90713_3 CDM 636 RC 49281-0860-10 NDC 90713 HCPCS outpatient 1 EA 20 15 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "POLIOVIRUS VACCINE, INACTIVATED (IPV), FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 90713_3 CDM 636 RC 49281-0860-10 NDC 90713 HCPCS outpatient 1 EA 20 15 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "POLIOVIRUS VACCINE, INACTIVATED (IPV), FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 90713_3 CDM 636 RC 49281-0860-10 NDC 90713 HCPCS outpatient 1 EA 20 15 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 18 90 999999999 15.6 19 percent of total billed charges "POLIOVIRUS VACCINE, INACTIVATED (IPV), FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 90713_3 CDM 636 RC 49281-0860-10 NDC 90713 HCPCS outpatient 1 EA 20 15 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 19 95 999999999 15.6 19 percent of total billed charges "POLIOVIRUS VACCINE, INACTIVATED (IPV), FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 90713_3 CDM 636 RC 49281-0860-10 NDC 90713 HCPCS outpatient 1 EA 20 15 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 19 95 999999999 15.6 19 percent of total billed charges "POLIOVIRUS VACCINE, INACTIVATED (IPV), FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 90713_3 CDM 636 RC 49281-0860-10 NDC 90713 HCPCS outpatient 1 EA 20 15 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 17.8 89 999999999 15.6 19 percent of total billed charges "POLIOVIRUS VACCINE, INACTIVATED (IPV), FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 90713_3 CDM 636 RC 49281-0860-10 NDC 90713 HCPCS outpatient 1 EA 20 15 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 17.6 88 999999999 15.6 19 percent of total billed charges "POLIOVIRUS VACCINE, INACTIVATED (IPV), FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 90713_3 CDM 636 RC 49281-0860-10 NDC 90713 HCPCS outpatient 1 EA 20 15 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), PRESERVATIVE FREE, WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 90714_3 CDM 250 RC 90714 HCPCS outpatient 85 63.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 76.5 90 999999999 66.3 80.75 percent of total billed charges "TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), PRESERVATIVE FREE, WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 90714_3 CDM 250 RC 90714 HCPCS outpatient 85 63.75 AETNA MCR ADV AETNA MCR ADV 66.3 78 999999999 66.3 80.75 percent of total billed charges "TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), PRESERVATIVE FREE, WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 90714_3 CDM 250 RC 90714 HCPCS outpatient 85 63.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 74.43 87.57 999999999 66.3 80.75 percent of total billed charges "TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), PRESERVATIVE FREE, WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 90714_3 CDM 250 RC 90714 HCPCS outpatient 85 63.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 72.31 85.07 999999999 66.3 80.75 percent of total billed charges "TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), PRESERVATIVE FREE, WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 90714_3 CDM 250 RC 90714 HCPCS outpatient 85 63.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 72.31 85.07 999999999 66.3 80.75 percent of total billed charges "TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), PRESERVATIVE FREE, WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 90714_3 CDM 250 RC 90714 HCPCS outpatient 85 63.75 MOLINA MCAID MOLINA MCAID 70.89 83.4 999999999 66.3 80.75 percent of total billed charges "TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), PRESERVATIVE FREE, WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 90714_3 CDM 250 RC 90714 HCPCS outpatient 85 63.75 MOLINA MCR ADV MOLINA MCR ADV 75.65 89 999999999 66.3 80.75 percent of total billed charges "TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), PRESERVATIVE FREE, WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 90714_3 CDM 250 RC 90714 HCPCS outpatient 85 63.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 75.65 89 999999999 66.3 80.75 percent of total billed charges "TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), PRESERVATIVE FREE, WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 90714_3 CDM 250 RC 90714 HCPCS outpatient 85 63.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 75.65 89 999999999 66.3 80.75 percent of total billed charges "TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), PRESERVATIVE FREE, WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 90714_3 CDM 250 RC 90714 HCPCS outpatient 85 63.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 76.5 90 999999999 66.3 80.75 percent of total billed charges "TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), PRESERVATIVE FREE, WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 90714_3 CDM 250 RC 90714 HCPCS outpatient 85 63.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 80.75 95 999999999 66.3 80.75 percent of total billed charges "TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), PRESERVATIVE FREE, WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 90714_3 CDM 250 RC 90714 HCPCS outpatient 85 63.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 80.75 95 999999999 66.3 80.75 percent of total billed charges "TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), PRESERVATIVE FREE, WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 90714_3 CDM 250 RC 90714 HCPCS outpatient 85 63.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 75.65 89 999999999 66.3 80.75 percent of total billed charges "TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), PRESERVATIVE FREE, WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 90714_3 CDM 250 RC 90714 HCPCS outpatient 85 63.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 74.8 88 999999999 66.3 80.75 percent of total billed charges "TETANUS AND DIPHTHERIA TOXOIDS ADSORBED (TD), PRESERVATIVE FREE, WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 90714_3 CDM 250 RC 90714 HCPCS outpatient 85 63.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 75.65 89 999999999 66.3 80.75 percent of total billed charges "TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACCINE (TDAP), WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 90715_3 CDM 920 RC 90715 HCPCS outpatient 20 15 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 18 90 999999999 15.6 19 percent of total billed charges "TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACCINE (TDAP), WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 90715_3 CDM 920 RC 90715 HCPCS outpatient 20 15 AETNA MCR ADV AETNA MCR ADV 15.6 78 999999999 15.6 19 percent of total billed charges "TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACCINE (TDAP), WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 90715_3 CDM 920 RC 90715 HCPCS outpatient 20 15 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 17.51 87.57 999999999 15.6 19 percent of total billed charges "TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACCINE (TDAP), WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 90715_3 CDM 920 RC 90715 HCPCS outpatient 20 15 COORDINATED CARE MCAID COORDINATED CARE MCAID 17.01 85.07 999999999 15.6 19 percent of total billed charges "TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACCINE (TDAP), WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 90715_3 CDM 920 RC 90715 HCPCS outpatient 20 15 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 17.01 85.07 999999999 15.6 19 percent of total billed charges "TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACCINE (TDAP), WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 90715_3 CDM 920 RC 90715 HCPCS outpatient 20 15 MOLINA MCAID MOLINA MCAID 16.68 83.4 999999999 15.6 19 percent of total billed charges "TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACCINE (TDAP), WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 90715_3 CDM 920 RC 90715 HCPCS outpatient 20 15 MOLINA MCR ADV MOLINA MCR ADV 17.8 89 999999999 15.6 19 percent of total billed charges "TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACCINE (TDAP), WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 90715_3 CDM 920 RC 90715 HCPCS outpatient 20 15 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACCINE (TDAP), WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 90715_3 CDM 920 RC 90715 HCPCS outpatient 20 15 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACCINE (TDAP), WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 90715_3 CDM 920 RC 90715 HCPCS outpatient 20 15 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 18 90 999999999 15.6 19 percent of total billed charges "TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACCINE (TDAP), WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 90715_3 CDM 920 RC 90715 HCPCS outpatient 20 15 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 19 95 999999999 15.6 19 percent of total billed charges "TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACCINE (TDAP), WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 90715_3 CDM 920 RC 90715 HCPCS outpatient 20 15 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 19 95 999999999 15.6 19 percent of total billed charges "TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACCINE (TDAP), WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 90715_3 CDM 920 RC 90715 HCPCS outpatient 20 15 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 17.8 89 999999999 15.6 19 percent of total billed charges "TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACCINE (TDAP), WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 90715_3 CDM 920 RC 90715 HCPCS outpatient 20 15 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 17.6 88 999999999 15.6 19 percent of total billed charges "TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACCINE (TDAP), WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 90715_3 CDM 920 RC 90715 HCPCS outpatient 20 15 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "VARICELLA VIRUS VACCINE (VAR), LIVE, FOR SUBCUTANEOUS USE" 90716_3 CDM 636 RC 00006-4827-00 NDC 90716 HCPCS outpatient 1350 EA 20 15 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 18 90 999999999 15.6 19 percent of total billed charges "VARICELLA VIRUS VACCINE (VAR), LIVE, FOR SUBCUTANEOUS USE" 90716_3 CDM 636 RC 00006-4827-00 NDC 90716 HCPCS outpatient 1350 EA 20 15 AETNA MCR ADV AETNA MCR ADV 15.6 78 999999999 15.6 19 percent of total billed charges "VARICELLA VIRUS VACCINE (VAR), LIVE, FOR SUBCUTANEOUS USE" 90716_3 CDM 636 RC 00006-4827-00 NDC 90716 HCPCS outpatient 1350 EA 20 15 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 17.51 87.57 999999999 15.6 19 percent of total billed charges "VARICELLA VIRUS VACCINE (VAR), LIVE, FOR SUBCUTANEOUS USE" 90716_3 CDM 636 RC 00006-4827-00 NDC 90716 HCPCS outpatient 1350 EA 20 15 COORDINATED CARE MCAID COORDINATED CARE MCAID 17.01 85.07 999999999 15.6 19 percent of total billed charges "VARICELLA VIRUS VACCINE (VAR), LIVE, FOR SUBCUTANEOUS USE" 90716_3 CDM 636 RC 00006-4827-00 NDC 90716 HCPCS outpatient 1350 EA 20 15 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 17.01 85.07 999999999 15.6 19 percent of total billed charges "VARICELLA VIRUS VACCINE (VAR), LIVE, FOR SUBCUTANEOUS USE" 90716_3 CDM 636 RC 00006-4827-00 NDC 90716 HCPCS outpatient 1350 EA 20 15 MOLINA MCAID MOLINA MCAID 16.68 83.4 999999999 15.6 19 percent of total billed charges "VARICELLA VIRUS VACCINE (VAR), LIVE, FOR SUBCUTANEOUS USE" 90716_3 CDM 636 RC 00006-4827-00 NDC 90716 HCPCS outpatient 1350 EA 20 15 MOLINA MCR ADV MOLINA MCR ADV 17.8 89 999999999 15.6 19 percent of total billed charges "VARICELLA VIRUS VACCINE (VAR), LIVE, FOR SUBCUTANEOUS USE" 90716_3 CDM 636 RC 00006-4827-00 NDC 90716 HCPCS outpatient 1350 EA 20 15 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "VARICELLA VIRUS VACCINE (VAR), LIVE, FOR SUBCUTANEOUS USE" 90716_3 CDM 636 RC 00006-4827-00 NDC 90716 HCPCS outpatient 1350 EA 20 15 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "VARICELLA VIRUS VACCINE (VAR), LIVE, FOR SUBCUTANEOUS USE" 90716_3 CDM 636 RC 00006-4827-00 NDC 90716 HCPCS outpatient 1350 EA 20 15 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 18 90 999999999 15.6 19 percent of total billed charges "VARICELLA VIRUS VACCINE (VAR), LIVE, FOR SUBCUTANEOUS USE" 90716_3 CDM 636 RC 00006-4827-00 NDC 90716 HCPCS outpatient 1350 EA 20 15 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 19 95 999999999 15.6 19 percent of total billed charges "VARICELLA VIRUS VACCINE (VAR), LIVE, FOR SUBCUTANEOUS USE" 90716_3 CDM 636 RC 00006-4827-00 NDC 90716 HCPCS outpatient 1350 EA 20 15 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 19 95 999999999 15.6 19 percent of total billed charges "VARICELLA VIRUS VACCINE (VAR), LIVE, FOR SUBCUTANEOUS USE" 90716_3 CDM 636 RC 00006-4827-00 NDC 90716 HCPCS outpatient 1350 EA 20 15 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 17.8 89 999999999 15.6 19 percent of total billed charges "VARICELLA VIRUS VACCINE (VAR), LIVE, FOR SUBCUTANEOUS USE" 90716_3 CDM 636 RC 00006-4827-00 NDC 90716 HCPCS outpatient 1350 EA 20 15 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 17.6 88 999999999 15.6 19 percent of total billed charges "VARICELLA VIRUS VACCINE (VAR), LIVE, FOR SUBCUTANEOUS USE" 90716_3 CDM 636 RC 00006-4827-00 NDC 90716 HCPCS outpatient 1350 EA 20 15 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, HEPATITIS B, AND INACTIVATED POLIOVIRUS VACCINE (DTAP-HEPB-IPV), FOR INTRAMUSCULAR USE" 90723_3 CDM 250 RC 58160-0811-52 NDC 90723 HCPCS outpatient 1 EA 20 15 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 17.6 88 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, HEPATITIS B, AND INACTIVATED POLIOVIRUS VACCINE (DTAP-HEPB-IPV), FOR INTRAMUSCULAR USE" 90723_3 CDM 250 RC 58160-0811-52 NDC 90723 HCPCS outpatient 1 EA 20 15 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, HEPATITIS B, AND INACTIVATED POLIOVIRUS VACCINE (DTAP-HEPB-IPV), FOR INTRAMUSCULAR USE" 90723_3 CDM 250 RC 58160-0811-52 NDC 90723 HCPCS outpatient 1 EA 20 15 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 18 90 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, HEPATITIS B, AND INACTIVATED POLIOVIRUS VACCINE (DTAP-HEPB-IPV), FOR INTRAMUSCULAR USE" 90723_3 CDM 250 RC 58160-0811-52 NDC 90723 HCPCS outpatient 1 EA 20 15 AETNA MCR ADV AETNA MCR ADV 15.6 78 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, HEPATITIS B, AND INACTIVATED POLIOVIRUS VACCINE (DTAP-HEPB-IPV), FOR INTRAMUSCULAR USE" 90723_3 CDM 250 RC 58160-0811-52 NDC 90723 HCPCS outpatient 1 EA 20 15 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 17.51 87.57 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, HEPATITIS B, AND INACTIVATED POLIOVIRUS VACCINE (DTAP-HEPB-IPV), FOR INTRAMUSCULAR USE" 90723_3 CDM 250 RC 58160-0811-52 NDC 90723 HCPCS outpatient 1 EA 20 15 COORDINATED CARE MCAID COORDINATED CARE MCAID 17.01 85.07 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, HEPATITIS B, AND INACTIVATED POLIOVIRUS VACCINE (DTAP-HEPB-IPV), FOR INTRAMUSCULAR USE" 90723_3 CDM 250 RC 58160-0811-52 NDC 90723 HCPCS outpatient 1 EA 20 15 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 17.01 85.07 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, HEPATITIS B, AND INACTIVATED POLIOVIRUS VACCINE (DTAP-HEPB-IPV), FOR INTRAMUSCULAR USE" 90723_3 CDM 250 RC 58160-0811-52 NDC 90723 HCPCS outpatient 1 EA 20 15 MOLINA MCAID MOLINA MCAID 16.68 83.4 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, HEPATITIS B, AND INACTIVATED POLIOVIRUS VACCINE (DTAP-HEPB-IPV), FOR INTRAMUSCULAR USE" 90723_3 CDM 250 RC 58160-0811-52 NDC 90723 HCPCS outpatient 1 EA 20 15 MOLINA MCR ADV MOLINA MCR ADV 17.8 89 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, HEPATITIS B, AND INACTIVATED POLIOVIRUS VACCINE (DTAP-HEPB-IPV), FOR INTRAMUSCULAR USE" 90723_3 CDM 250 RC 58160-0811-52 NDC 90723 HCPCS outpatient 1 EA 20 15 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, HEPATITIS B, AND INACTIVATED POLIOVIRUS VACCINE (DTAP-HEPB-IPV), FOR INTRAMUSCULAR USE" 90723_3 CDM 250 RC 58160-0811-52 NDC 90723 HCPCS outpatient 1 EA 20 15 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, HEPATITIS B, AND INACTIVATED POLIOVIRUS VACCINE (DTAP-HEPB-IPV), FOR INTRAMUSCULAR USE" 90723_3 CDM 250 RC 58160-0811-52 NDC 90723 HCPCS outpatient 1 EA 20 15 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 18 90 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, HEPATITIS B, AND INACTIVATED POLIOVIRUS VACCINE (DTAP-HEPB-IPV), FOR INTRAMUSCULAR USE" 90723_3 CDM 250 RC 58160-0811-52 NDC 90723 HCPCS outpatient 1 EA 20 15 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 19 95 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, HEPATITIS B, AND INACTIVATED POLIOVIRUS VACCINE (DTAP-HEPB-IPV), FOR INTRAMUSCULAR USE" 90723_3 CDM 250 RC 58160-0811-52 NDC 90723 HCPCS outpatient 1 EA 20 15 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 19 95 999999999 15.6 19 percent of total billed charges "DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, HEPATITIS B, AND INACTIVATED POLIOVIRUS VACCINE (DTAP-HEPB-IPV), FOR INTRAMUSCULAR USE" 90723_3 CDM 250 RC 58160-0811-52 NDC 90723 HCPCS outpatient 1 EA 20 15 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 17.8 89 999999999 15.6 19 percent of total billed charges "PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT (PPSV23), ADULT OR IMMUNOSUPPRESSED PATIENT DOSAGE, WHEN ADMINISTERED TO INDIVIDUALS 2 YEARS OR OLDER, FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 90732_3 CDM 636 RC 00006-4943-01 NDC 90732 HCPCS outpatient 25 EA 177 132.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 159.3 90 999999999 138.06 168.15 percent of total billed charges "PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT (PPSV23), ADULT OR IMMUNOSUPPRESSED PATIENT DOSAGE, WHEN ADMINISTERED TO INDIVIDUALS 2 YEARS OR OLDER, FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 90732_3 CDM 636 RC 00006-4943-01 NDC 90732 HCPCS outpatient 25 EA 177 132.75 AETNA MCR ADV AETNA MCR ADV 138.06 78 999999999 138.06 168.15 percent of total billed charges "PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT (PPSV23), ADULT OR IMMUNOSUPPRESSED PATIENT DOSAGE, WHEN ADMINISTERED TO INDIVIDUALS 2 YEARS OR OLDER, FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 90732_3 CDM 636 RC 00006-4943-01 NDC 90732 HCPCS outpatient 25 EA 177 132.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 155 87.57 999999999 138.06 168.15 percent of total billed charges "PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT (PPSV23), ADULT OR IMMUNOSUPPRESSED PATIENT DOSAGE, WHEN ADMINISTERED TO INDIVIDUALS 2 YEARS OR OLDER, FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 90732_3 CDM 636 RC 00006-4943-01 NDC 90732 HCPCS outpatient 25 EA 177 132.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 150.57 85.07 999999999 138.06 168.15 percent of total billed charges "PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT (PPSV23), ADULT OR IMMUNOSUPPRESSED PATIENT DOSAGE, WHEN ADMINISTERED TO INDIVIDUALS 2 YEARS OR OLDER, FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 90732_3 CDM 636 RC 00006-4943-01 NDC 90732 HCPCS outpatient 25 EA 177 132.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 150.57 85.07 999999999 138.06 168.15 percent of total billed charges "PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT (PPSV23), ADULT OR IMMUNOSUPPRESSED PATIENT DOSAGE, WHEN ADMINISTERED TO INDIVIDUALS 2 YEARS OR OLDER, FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 90732_3 CDM 636 RC 00006-4943-01 NDC 90732 HCPCS outpatient 25 EA 177 132.75 MOLINA MCAID MOLINA MCAID 147.62 83.4 999999999 138.06 168.15 percent of total billed charges "PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT (PPSV23), ADULT OR IMMUNOSUPPRESSED PATIENT DOSAGE, WHEN ADMINISTERED TO INDIVIDUALS 2 YEARS OR OLDER, FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 90732_3 CDM 636 RC 00006-4943-01 NDC 90732 HCPCS outpatient 25 EA 177 132.75 MOLINA MCR ADV MOLINA MCR ADV 157.53 89 999999999 138.06 168.15 percent of total billed charges "PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT (PPSV23), ADULT OR IMMUNOSUPPRESSED PATIENT DOSAGE, WHEN ADMINISTERED TO INDIVIDUALS 2 YEARS OR OLDER, FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 90732_3 CDM 636 RC 00006-4943-01 NDC 90732 HCPCS outpatient 25 EA 177 132.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 157.53 89 999999999 138.06 168.15 percent of total billed charges "PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT (PPSV23), ADULT OR IMMUNOSUPPRESSED PATIENT DOSAGE, WHEN ADMINISTERED TO INDIVIDUALS 2 YEARS OR OLDER, FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 90732_3 CDM 636 RC 00006-4943-01 NDC 90732 HCPCS outpatient 25 EA 177 132.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 157.53 89 999999999 138.06 168.15 percent of total billed charges "PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT (PPSV23), ADULT OR IMMUNOSUPPRESSED PATIENT DOSAGE, WHEN ADMINISTERED TO INDIVIDUALS 2 YEARS OR OLDER, FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 90732_3 CDM 636 RC 00006-4943-01 NDC 90732 HCPCS outpatient 25 EA 177 132.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 159.3 90 999999999 138.06 168.15 percent of total billed charges "PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT (PPSV23), ADULT OR IMMUNOSUPPRESSED PATIENT DOSAGE, WHEN ADMINISTERED TO INDIVIDUALS 2 YEARS OR OLDER, FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 90732_3 CDM 636 RC 00006-4943-01 NDC 90732 HCPCS outpatient 25 EA 177 132.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 168.15 95 999999999 138.06 168.15 percent of total billed charges "PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT (PPSV23), ADULT OR IMMUNOSUPPRESSED PATIENT DOSAGE, WHEN ADMINISTERED TO INDIVIDUALS 2 YEARS OR OLDER, FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 90732_3 CDM 636 RC 00006-4943-01 NDC 90732 HCPCS outpatient 25 EA 177 132.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 168.15 95 999999999 138.06 168.15 percent of total billed charges "PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT (PPSV23), ADULT OR IMMUNOSUPPRESSED PATIENT DOSAGE, WHEN ADMINISTERED TO INDIVIDUALS 2 YEARS OR OLDER, FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 90732_3 CDM 636 RC 00006-4943-01 NDC 90732 HCPCS outpatient 25 EA 177 132.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 157.53 89 999999999 138.06 168.15 percent of total billed charges "PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT (PPSV23), ADULT OR IMMUNOSUPPRESSED PATIENT DOSAGE, WHEN ADMINISTERED TO INDIVIDUALS 2 YEARS OR OLDER, FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 90732_3 CDM 636 RC 00006-4943-01 NDC 90732 HCPCS outpatient 25 EA 177 132.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 155.76 88 999999999 138.06 168.15 percent of total billed charges "PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT (PPSV23), ADULT OR IMMUNOSUPPRESSED PATIENT DOSAGE, WHEN ADMINISTERED TO INDIVIDUALS 2 YEARS OR OLDER, FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 90732_3 CDM 636 RC 00006-4943-01 NDC 90732 HCPCS outpatient 25 EA 177 132.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 157.53 89 999999999 138.06 168.15 percent of total billed charges "MENINGOCOCCAL POLYSACCHARIDE VACCINE, SEROGROUPS A, C, Y, W-135, QUADRIVALENT (MPSV4), FOR SUBCUTANEOUS USE" 90733_3 CDM 636 RC 90733 HCPCS outpatient 20 15 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 18 90 999999999 15.6 19 percent of total billed charges "MENINGOCOCCAL POLYSACCHARIDE VACCINE, SEROGROUPS A, C, Y, W-135, QUADRIVALENT (MPSV4), FOR SUBCUTANEOUS USE" 90733_3 CDM 636 RC 90733 HCPCS outpatient 20 15 AETNA MCR ADV AETNA MCR ADV 15.6 78 999999999 15.6 19 percent of total billed charges "MENINGOCOCCAL POLYSACCHARIDE VACCINE, SEROGROUPS A, C, Y, W-135, QUADRIVALENT (MPSV4), FOR SUBCUTANEOUS USE" 90733_3 CDM 636 RC 90733 HCPCS outpatient 20 15 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 17.51 87.57 999999999 15.6 19 percent of total billed charges "MENINGOCOCCAL POLYSACCHARIDE VACCINE, SEROGROUPS A, C, Y, W-135, QUADRIVALENT (MPSV4), FOR SUBCUTANEOUS USE" 90733_3 CDM 636 RC 90733 HCPCS outpatient 20 15 COORDINATED CARE MCAID COORDINATED CARE MCAID 17.01 85.07 999999999 15.6 19 percent of total billed charges "MENINGOCOCCAL POLYSACCHARIDE VACCINE, SEROGROUPS A, C, Y, W-135, QUADRIVALENT (MPSV4), FOR SUBCUTANEOUS USE" 90733_3 CDM 636 RC 90733 HCPCS outpatient 20 15 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 17.01 85.07 999999999 15.6 19 percent of total billed charges "MENINGOCOCCAL POLYSACCHARIDE VACCINE, SEROGROUPS A, C, Y, W-135, QUADRIVALENT (MPSV4), FOR SUBCUTANEOUS USE" 90733_3 CDM 636 RC 90733 HCPCS outpatient 20 15 MOLINA MCAID MOLINA MCAID 16.68 83.4 999999999 15.6 19 percent of total billed charges "MENINGOCOCCAL POLYSACCHARIDE VACCINE, SEROGROUPS A, C, Y, W-135, QUADRIVALENT (MPSV4), FOR SUBCUTANEOUS USE" 90733_3 CDM 636 RC 90733 HCPCS outpatient 20 15 MOLINA MCR ADV MOLINA MCR ADV 17.8 89 999999999 15.6 19 percent of total billed charges "MENINGOCOCCAL POLYSACCHARIDE VACCINE, SEROGROUPS A, C, Y, W-135, QUADRIVALENT (MPSV4), FOR SUBCUTANEOUS USE" 90733_3 CDM 636 RC 90733 HCPCS outpatient 20 15 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "MENINGOCOCCAL POLYSACCHARIDE VACCINE, SEROGROUPS A, C, Y, W-135, QUADRIVALENT (MPSV4), FOR SUBCUTANEOUS USE" 90733_3 CDM 636 RC 90733 HCPCS outpatient 20 15 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "MENINGOCOCCAL POLYSACCHARIDE VACCINE, SEROGROUPS A, C, Y, W-135, QUADRIVALENT (MPSV4), FOR SUBCUTANEOUS USE" 90733_3 CDM 636 RC 90733 HCPCS outpatient 20 15 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 18 90 999999999 15.6 19 percent of total billed charges "MENINGOCOCCAL POLYSACCHARIDE VACCINE, SEROGROUPS A, C, Y, W-135, QUADRIVALENT (MPSV4), FOR SUBCUTANEOUS USE" 90733_3 CDM 636 RC 90733 HCPCS outpatient 20 15 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 19 95 999999999 15.6 19 percent of total billed charges "MENINGOCOCCAL POLYSACCHARIDE VACCINE, SEROGROUPS A, C, Y, W-135, QUADRIVALENT (MPSV4), FOR SUBCUTANEOUS USE" 90733_3 CDM 636 RC 90733 HCPCS outpatient 20 15 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 19 95 999999999 15.6 19 percent of total billed charges "MENINGOCOCCAL POLYSACCHARIDE VACCINE, SEROGROUPS A, C, Y, W-135, QUADRIVALENT (MPSV4), FOR SUBCUTANEOUS USE" 90733_3 CDM 636 RC 90733 HCPCS outpatient 20 15 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 17.8 89 999999999 15.6 19 percent of total billed charges "MENINGOCOCCAL POLYSACCHARIDE VACCINE, SEROGROUPS A, C, Y, W-135, QUADRIVALENT (MPSV4), FOR SUBCUTANEOUS USE" 90733_3 CDM 636 RC 90733 HCPCS outpatient 20 15 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 17.6 88 999999999 15.6 19 percent of total billed charges "MENINGOCOCCAL POLYSACCHARIDE VACCINE, SEROGROUPS A, C, Y, W-135, QUADRIVALENT (MPSV4), FOR SUBCUTANEOUS USE" 90733_3 CDM 636 RC 90733 HCPCS outpatient 20 15 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "MENINGOCOCCAL CONJUGATE VACCINE, SEROGROUPS A, C, W, Y, QUADRIVALENT, DIPHTHERIA TOXOID CARRIER (MENACWY-D) OR CRM197 CARRIER (MENACWY-CRM), FOR INTRAMUSCULAR USE" 90734_3 CDM 250 RC 49281-0589-58 NDC 90734 HCPCS outpatient 4 EA 177 132.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 159.3 90 999999999 138.06 168.15 percent of total billed charges "MENINGOCOCCAL CONJUGATE VACCINE, SEROGROUPS A, C, W, Y, QUADRIVALENT, DIPHTHERIA TOXOID CARRIER (MENACWY-D) OR CRM197 CARRIER (MENACWY-CRM), FOR INTRAMUSCULAR USE" 90734_3 CDM 250 RC 49281-0589-58 NDC 90734 HCPCS outpatient 4 EA 177 132.75 AETNA MCR ADV AETNA MCR ADV 138.06 78 999999999 138.06 168.15 percent of total billed charges "MENINGOCOCCAL CONJUGATE VACCINE, SEROGROUPS A, C, W, Y, QUADRIVALENT, DIPHTHERIA TOXOID CARRIER (MENACWY-D) OR CRM197 CARRIER (MENACWY-CRM), FOR INTRAMUSCULAR USE" 90734_3 CDM 250 RC 49281-0589-58 NDC 90734 HCPCS outpatient 4 EA 177 132.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 155 87.57 999999999 138.06 168.15 percent of total billed charges "MENINGOCOCCAL CONJUGATE VACCINE, SEROGROUPS A, C, W, Y, QUADRIVALENT, DIPHTHERIA TOXOID CARRIER (MENACWY-D) OR CRM197 CARRIER (MENACWY-CRM), FOR INTRAMUSCULAR USE" 90734_3 CDM 250 RC 49281-0589-58 NDC 90734 HCPCS outpatient 4 EA 177 132.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 150.57 85.07 999999999 138.06 168.15 percent of total billed charges "MENINGOCOCCAL CONJUGATE VACCINE, SEROGROUPS A, C, W, Y, QUADRIVALENT, DIPHTHERIA TOXOID CARRIER (MENACWY-D) OR CRM197 CARRIER (MENACWY-CRM), FOR INTRAMUSCULAR USE" 90734_3 CDM 250 RC 49281-0589-58 NDC 90734 HCPCS outpatient 4 EA 177 132.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 150.57 85.07 999999999 138.06 168.15 percent of total billed charges "MENINGOCOCCAL CONJUGATE VACCINE, SEROGROUPS A, C, W, Y, QUADRIVALENT, DIPHTHERIA TOXOID CARRIER (MENACWY-D) OR CRM197 CARRIER (MENACWY-CRM), FOR INTRAMUSCULAR USE" 90734_3 CDM 250 RC 49281-0589-58 NDC 90734 HCPCS outpatient 4 EA 177 132.75 MOLINA MCAID MOLINA MCAID 147.62 83.4 999999999 138.06 168.15 percent of total billed charges "MENINGOCOCCAL CONJUGATE VACCINE, SEROGROUPS A, C, W, Y, QUADRIVALENT, DIPHTHERIA TOXOID CARRIER (MENACWY-D) OR CRM197 CARRIER (MENACWY-CRM), FOR INTRAMUSCULAR USE" 90734_3 CDM 250 RC 49281-0589-58 NDC 90734 HCPCS outpatient 4 EA 177 132.75 MOLINA MCR ADV MOLINA MCR ADV 157.53 89 999999999 138.06 168.15 percent of total billed charges "MENINGOCOCCAL CONJUGATE VACCINE, SEROGROUPS A, C, W, Y, QUADRIVALENT, DIPHTHERIA TOXOID CARRIER (MENACWY-D) OR CRM197 CARRIER (MENACWY-CRM), FOR INTRAMUSCULAR USE" 90734_3 CDM 250 RC 49281-0589-58 NDC 90734 HCPCS outpatient 4 EA 177 132.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 157.53 89 999999999 138.06 168.15 percent of total billed charges "MENINGOCOCCAL CONJUGATE VACCINE, SEROGROUPS A, C, W, Y, QUADRIVALENT, DIPHTHERIA TOXOID CARRIER (MENACWY-D) OR CRM197 CARRIER (MENACWY-CRM), FOR INTRAMUSCULAR USE" 90734_3 CDM 250 RC 49281-0589-58 NDC 90734 HCPCS outpatient 4 EA 177 132.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 157.53 89 999999999 138.06 168.15 percent of total billed charges "MENINGOCOCCAL CONJUGATE VACCINE, SEROGROUPS A, C, W, Y, QUADRIVALENT, DIPHTHERIA TOXOID CARRIER (MENACWY-D) OR CRM197 CARRIER (MENACWY-CRM), FOR INTRAMUSCULAR USE" 90734_3 CDM 250 RC 49281-0589-58 NDC 90734 HCPCS outpatient 4 EA 177 132.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 159.3 90 999999999 138.06 168.15 percent of total billed charges "MENINGOCOCCAL CONJUGATE VACCINE, SEROGROUPS A, C, W, Y, QUADRIVALENT, DIPHTHERIA TOXOID CARRIER (MENACWY-D) OR CRM197 CARRIER (MENACWY-CRM), FOR INTRAMUSCULAR USE" 90734_3 CDM 250 RC 49281-0589-58 NDC 90734 HCPCS outpatient 4 EA 177 132.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 168.15 95 999999999 138.06 168.15 percent of total billed charges "MENINGOCOCCAL CONJUGATE VACCINE, SEROGROUPS A, C, W, Y, QUADRIVALENT, DIPHTHERIA TOXOID CARRIER (MENACWY-D) OR CRM197 CARRIER (MENACWY-CRM), FOR INTRAMUSCULAR USE" 90734_3 CDM 250 RC 49281-0589-58 NDC 90734 HCPCS outpatient 4 EA 177 132.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 168.15 95 999999999 138.06 168.15 percent of total billed charges "MENINGOCOCCAL CONJUGATE VACCINE, SEROGROUPS A, C, W, Y, QUADRIVALENT, DIPHTHERIA TOXOID CARRIER (MENACWY-D) OR CRM197 CARRIER (MENACWY-CRM), FOR INTRAMUSCULAR USE" 90734_3 CDM 250 RC 49281-0589-58 NDC 90734 HCPCS outpatient 4 EA 177 132.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 157.53 89 999999999 138.06 168.15 percent of total billed charges "MENINGOCOCCAL CONJUGATE VACCINE, SEROGROUPS A, C, W, Y, QUADRIVALENT, DIPHTHERIA TOXOID CARRIER (MENACWY-D) OR CRM197 CARRIER (MENACWY-CRM), FOR INTRAMUSCULAR USE" 90734_3 CDM 250 RC 49281-0589-58 NDC 90734 HCPCS outpatient 4 EA 177 132.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 155.76 88 999999999 138.06 168.15 percent of total billed charges "MENINGOCOCCAL CONJUGATE VACCINE, SEROGROUPS A, C, W, Y, QUADRIVALENT, DIPHTHERIA TOXOID CARRIER (MENACWY-D) OR CRM197 CARRIER (MENACWY-CRM), FOR INTRAMUSCULAR USE" 90734_3 CDM 250 RC 49281-0589-58 NDC 90734 HCPCS outpatient 4 EA 177 132.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 157.53 89 999999999 138.06 168.15 percent of total billed charges "HEPATITIS B VACCINE (HEPB), CPG-ADJUVANTED, ADULT DOSAGE, 2 DOSE OR 4 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90739_3 CDM 960 RC 58160-0821-43 NDC 90739 HCPCS outpatient 20 EA 20 15 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 177.56 999999999 20 177.56 fee schedule "HEPATITIS B VACCINE (HEPB), CPG-ADJUVANTED, ADULT DOSAGE, 2 DOSE OR 4 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90739_3 CDM 960 RC 58160-0821-43 NDC 90739 HCPCS outpatient 20 EA 20 15 AETNA MCR ADV AETNA MCR ADV 20 999999999 20 177.56 fee schedule "HEPATITIS B VACCINE (HEPB), CPG-ADJUVANTED, ADULT DOSAGE, 2 DOSE OR 4 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90739_3 CDM 960 RC 58160-0821-43 NDC 90739 HCPCS outpatient 20 EA 20 15 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 21 999999999 20 177.56 fee schedule "HEPATITIS B VACCINE (HEPB), CPG-ADJUVANTED, ADULT DOSAGE, 2 DOSE OR 4 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90739_3 CDM 960 RC 58160-0821-43 NDC 90739 HCPCS outpatient 20 EA 20 15 COORDINATED CARE MCAID COORDINATED CARE MCAID 20 999999999 20 177.56 fee schedule "HEPATITIS B VACCINE (HEPB), CPG-ADJUVANTED, ADULT DOSAGE, 2 DOSE OR 4 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90739_3 CDM 960 RC 58160-0821-43 NDC 90739 HCPCS outpatient 20 EA 20 15 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 20 999999999 20 177.56 fee schedule "HEPATITIS B VACCINE (HEPB), CPG-ADJUVANTED, ADULT DOSAGE, 2 DOSE OR 4 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90739_3 CDM 960 RC 58160-0821-43 NDC 90739 HCPCS outpatient 20 EA 20 15 MOLINA MCAID MOLINA MCAID 21 999999999 20 177.56 fee schedule "HEPATITIS B VACCINE (HEPB), CPG-ADJUVANTED, ADULT DOSAGE, 2 DOSE OR 4 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90739_3 CDM 960 RC 58160-0821-43 NDC 90739 HCPCS outpatient 20 EA 20 15 MOLINA MCR ADV MOLINA MCR ADV 20 999999999 20 177.56 fee schedule "HEPATITIS B VACCINE (HEPB), CPG-ADJUVANTED, ADULT DOSAGE, 2 DOSE OR 4 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90739_3 CDM 960 RC 58160-0821-43 NDC 90739 HCPCS outpatient 20 EA 20 15 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 20 999999999 20 177.56 fee schedule "HEPATITIS B VACCINE (HEPB), CPG-ADJUVANTED, ADULT DOSAGE, 2 DOSE OR 4 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90739_3 CDM 960 RC 58160-0821-43 NDC 90739 HCPCS outpatient 20 EA 20 15 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 20 999999999 20 177.56 fee schedule "HEPATITIS B VACCINE (HEPB), CPG-ADJUVANTED, ADULT DOSAGE, 2 DOSE OR 4 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90739_3 CDM 960 RC 58160-0821-43 NDC 90739 HCPCS outpatient 20 EA 20 15 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 177.16 999999999 20 177.56 fee schedule "HEPATITIS B VACCINE (HEPB), CPG-ADJUVANTED, ADULT DOSAGE, 2 DOSE OR 4 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90739_3 CDM 960 RC 58160-0821-43 NDC 90739 HCPCS outpatient 20 EA 20 15 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 999999999 20 177.56 "HEPATITIS B VACCINE (HEPB), CPG-ADJUVANTED, ADULT DOSAGE, 2 DOSE OR 4 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90739_3 CDM 960 RC 58160-0821-43 NDC 90739 HCPCS outpatient 20 EA 20 15 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 999999999 20 177.56 "HEPATITIS B VACCINE (HEPB), CPG-ADJUVANTED, ADULT DOSAGE, 2 DOSE OR 4 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90739_3 CDM 960 RC 58160-0821-43 NDC 90739 HCPCS outpatient 20 EA 20 15 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 20 999999999 20 177.56 fee schedule "HEPATITIS B VACCINE (HEPB), CPG-ADJUVANTED, ADULT DOSAGE, 2 DOSE OR 4 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90739_3 CDM 960 RC 58160-0821-43 NDC 90739 HCPCS outpatient 20 EA 20 15 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 177.16 999999999 20 177.56 fee schedule "HEPATITIS B VACCINE (HEPB), CPG-ADJUVANTED, ADULT DOSAGE, 2 DOSE OR 4 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90739_3 CDM 960 RC 58160-0821-43 NDC 90739 HCPCS outpatient 20 EA 20 15 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 20 999999999 20 177.56 fee schedule "HEPATITIS B VACCINE (HEPB), ADOLESCENT, 2 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90743_3 CDM 636 RC 90743 HCPCS outpatient 177 132.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 159.3 90 999999999 138.06 168.15 percent of total billed charges "HEPATITIS B VACCINE (HEPB), ADOLESCENT, 2 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90743_3 CDM 636 RC 90743 HCPCS outpatient 177 132.75 AETNA MCR ADV AETNA MCR ADV 138.06 78 999999999 138.06 168.15 percent of total billed charges "HEPATITIS B VACCINE (HEPB), ADOLESCENT, 2 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90743_3 CDM 636 RC 90743 HCPCS outpatient 177 132.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 155 87.57 999999999 138.06 168.15 percent of total billed charges "HEPATITIS B VACCINE (HEPB), ADOLESCENT, 2 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90743_3 CDM 636 RC 90743 HCPCS outpatient 177 132.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 150.57 85.07 999999999 138.06 168.15 percent of total billed charges "HEPATITIS B VACCINE (HEPB), ADOLESCENT, 2 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90743_3 CDM 636 RC 90743 HCPCS outpatient 177 132.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 150.57 85.07 999999999 138.06 168.15 percent of total billed charges "HEPATITIS B VACCINE (HEPB), ADOLESCENT, 2 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90743_3 CDM 636 RC 90743 HCPCS outpatient 177 132.75 MOLINA MCAID MOLINA MCAID 147.62 83.4 999999999 138.06 168.15 percent of total billed charges "HEPATITIS B VACCINE (HEPB), ADOLESCENT, 2 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90743_3 CDM 636 RC 90743 HCPCS outpatient 177 132.75 MOLINA MCR ADV MOLINA MCR ADV 157.53 89 999999999 138.06 168.15 percent of total billed charges "HEPATITIS B VACCINE (HEPB), ADOLESCENT, 2 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90743_3 CDM 636 RC 90743 HCPCS outpatient 177 132.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 157.53 89 999999999 138.06 168.15 percent of total billed charges "HEPATITIS B VACCINE (HEPB), ADOLESCENT, 2 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90743_3 CDM 636 RC 90743 HCPCS outpatient 177 132.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 157.53 89 999999999 138.06 168.15 percent of total billed charges "HEPATITIS B VACCINE (HEPB), ADOLESCENT, 2 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90743_3 CDM 636 RC 90743 HCPCS outpatient 177 132.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 159.3 90 999999999 138.06 168.15 percent of total billed charges "HEPATITIS B VACCINE (HEPB), ADOLESCENT, 2 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90743_3 CDM 636 RC 90743 HCPCS outpatient 177 132.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 168.15 95 999999999 138.06 168.15 percent of total billed charges "HEPATITIS B VACCINE (HEPB), ADOLESCENT, 2 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90743_3 CDM 636 RC 90743 HCPCS outpatient 177 132.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 168.15 95 999999999 138.06 168.15 percent of total billed charges "HEPATITIS B VACCINE (HEPB), ADOLESCENT, 2 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90743_3 CDM 636 RC 90743 HCPCS outpatient 177 132.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 157.53 89 999999999 138.06 168.15 percent of total billed charges "HEPATITIS B VACCINE (HEPB), ADOLESCENT, 2 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90743_3 CDM 636 RC 90743 HCPCS outpatient 177 132.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 155.76 88 999999999 138.06 168.15 percent of total billed charges "HEPATITIS B VACCINE (HEPB), ADOLESCENT, 2 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90743_3 CDM 636 RC 90743 HCPCS outpatient 177 132.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 157.53 89 999999999 138.06 168.15 percent of total billed charges "HEPATITIS B VACCINE (HEPB), PEDIATRIC/ADOLESCENT DOSAGE, 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90744_3 CDM 250 RC 90744 HCPCS outpatient 20 15 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 18 90 999999999 15.6 19 percent of total billed charges "HEPATITIS B VACCINE (HEPB), PEDIATRIC/ADOLESCENT DOSAGE, 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90744_3 CDM 250 RC 90744 HCPCS outpatient 20 15 AETNA MCR ADV AETNA MCR ADV 15.6 78 999999999 15.6 19 percent of total billed charges "HEPATITIS B VACCINE (HEPB), PEDIATRIC/ADOLESCENT DOSAGE, 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90744_3 CDM 250 RC 90744 HCPCS outpatient 20 15 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 17.51 87.57 999999999 15.6 19 percent of total billed charges "HEPATITIS B VACCINE (HEPB), PEDIATRIC/ADOLESCENT DOSAGE, 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90744_3 CDM 250 RC 90744 HCPCS outpatient 20 15 COORDINATED CARE MCAID COORDINATED CARE MCAID 17.01 85.07 999999999 15.6 19 percent of total billed charges "HEPATITIS B VACCINE (HEPB), PEDIATRIC/ADOLESCENT DOSAGE, 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90744_3 CDM 250 RC 90744 HCPCS outpatient 20 15 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 17.01 85.07 999999999 15.6 19 percent of total billed charges "HEPATITIS B VACCINE (HEPB), PEDIATRIC/ADOLESCENT DOSAGE, 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90744_3 CDM 250 RC 90744 HCPCS outpatient 20 15 MOLINA MCAID MOLINA MCAID 16.68 83.4 999999999 15.6 19 percent of total billed charges "HEPATITIS B VACCINE (HEPB), PEDIATRIC/ADOLESCENT DOSAGE, 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90744_3 CDM 250 RC 90744 HCPCS outpatient 20 15 MOLINA MCR ADV MOLINA MCR ADV 17.8 89 999999999 15.6 19 percent of total billed charges "HEPATITIS B VACCINE (HEPB), PEDIATRIC/ADOLESCENT DOSAGE, 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90744_3 CDM 250 RC 90744 HCPCS outpatient 20 15 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "HEPATITIS B VACCINE (HEPB), PEDIATRIC/ADOLESCENT DOSAGE, 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90744_3 CDM 250 RC 90744 HCPCS outpatient 20 15 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "HEPATITIS B VACCINE (HEPB), PEDIATRIC/ADOLESCENT DOSAGE, 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90744_3 CDM 250 RC 90744 HCPCS outpatient 20 15 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 18 90 999999999 15.6 19 percent of total billed charges "HEPATITIS B VACCINE (HEPB), PEDIATRIC/ADOLESCENT DOSAGE, 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90744_3 CDM 250 RC 90744 HCPCS outpatient 20 15 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 19 95 999999999 15.6 19 percent of total billed charges "HEPATITIS B VACCINE (HEPB), PEDIATRIC/ADOLESCENT DOSAGE, 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90744_3 CDM 250 RC 90744 HCPCS outpatient 20 15 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 19 95 999999999 15.6 19 percent of total billed charges "HEPATITIS B VACCINE (HEPB), PEDIATRIC/ADOLESCENT DOSAGE, 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90744_3 CDM 250 RC 90744 HCPCS outpatient 20 15 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 17.8 89 999999999 15.6 19 percent of total billed charges "HEPATITIS B VACCINE (HEPB), PEDIATRIC/ADOLESCENT DOSAGE, 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90744_3 CDM 250 RC 90744 HCPCS outpatient 20 15 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 17.6 88 999999999 15.6 19 percent of total billed charges "HEPATITIS B VACCINE (HEPB), PEDIATRIC/ADOLESCENT DOSAGE, 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90744_3 CDM 250 RC 90744 HCPCS outpatient 20 15 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 17.8 89 999999999 15.6 19 percent of total billed charges "HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90746_3 CDM 636 RC 90746 HCPCS outpatient 104 78 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 93.6 90 999999999 81.12 98.8 percent of total billed charges "HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90746_3 CDM 636 RC 90746 HCPCS outpatient 104 78 AETNA MCR ADV AETNA MCR ADV 81.12 78 999999999 81.12 98.8 percent of total billed charges "HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90746_3 CDM 636 RC 90746 HCPCS outpatient 104 78 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 91.07 87.57 999999999 81.12 98.8 percent of total billed charges "HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90746_3 CDM 636 RC 90746 HCPCS outpatient 104 78 COORDINATED CARE MCAID COORDINATED CARE MCAID 88.47 85.07 999999999 81.12 98.8 percent of total billed charges "HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90746_3 CDM 636 RC 90746 HCPCS outpatient 104 78 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 88.47 85.07 999999999 81.12 98.8 percent of total billed charges "HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90746_3 CDM 636 RC 90746 HCPCS outpatient 104 78 MOLINA MCAID MOLINA MCAID 86.74 83.4 999999999 81.12 98.8 percent of total billed charges "HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90746_3 CDM 636 RC 90746 HCPCS outpatient 104 78 MOLINA MCR ADV MOLINA MCR ADV 92.56 89 999999999 81.12 98.8 percent of total billed charges "HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90746_3 CDM 636 RC 90746 HCPCS outpatient 104 78 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 92.56 89 999999999 81.12 98.8 percent of total billed charges "HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90746_3 CDM 636 RC 90746 HCPCS outpatient 104 78 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 92.56 89 999999999 81.12 98.8 percent of total billed charges "HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90746_3 CDM 636 RC 90746 HCPCS outpatient 104 78 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 93.6 90 999999999 81.12 98.8 percent of total billed charges "HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90746_3 CDM 636 RC 90746 HCPCS outpatient 104 78 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 98.8 95 999999999 81.12 98.8 percent of total billed charges "HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90746_3 CDM 636 RC 90746 HCPCS outpatient 104 78 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 98.8 95 999999999 81.12 98.8 percent of total billed charges "HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90746_3 CDM 636 RC 90746 HCPCS outpatient 104 78 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 92.56 89 999999999 81.12 98.8 percent of total billed charges "HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90746_3 CDM 636 RC 90746 HCPCS outpatient 104 78 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 91.52 88 999999999 81.12 98.8 percent of total billed charges "HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE" 90746_3 CDM 636 RC 90746 HCPCS outpatient 104 78 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 92.56 89 999999999 81.12 98.8 percent of total billed charges PSYCHIATRIC DIAGNOSTIC EVALUATION 90791_3 CDM 960 RC 90791 HCPCS outpatient 294 220.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 146.94 999999999 103.28 294 fee schedule PSYCHIATRIC DIAGNOSTIC EVALUATION 90791_3 CDM 960 RC 90791 HCPCS outpatient 294 220.5 AETNA MCR ADV AETNA MCR ADV 294 999999999 103.28 294 fee schedule PSYCHIATRIC DIAGNOSTIC EVALUATION 90791_3 CDM 960 RC 90791 HCPCS outpatient 294 220.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 108.44 999999999 103.28 294 fee schedule PSYCHIATRIC DIAGNOSTIC EVALUATION 90791_3 CDM 960 RC 90791 HCPCS outpatient 294 220.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 103.28 999999999 103.28 294 fee schedule PSYCHIATRIC DIAGNOSTIC EVALUATION 90791_3 CDM 960 RC 90791 HCPCS outpatient 294 220.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 294 999999999 103.28 294 fee schedule PSYCHIATRIC DIAGNOSTIC EVALUATION 90791_3 CDM 960 RC 90791 HCPCS outpatient 294 220.5 MOLINA MCAID MOLINA MCAID 108.44 999999999 103.28 294 fee schedule PSYCHIATRIC DIAGNOSTIC EVALUATION 90791_3 CDM 960 RC 90791 HCPCS outpatient 294 220.5 MOLINA MCR ADV MOLINA MCR ADV 294 999999999 103.28 294 fee schedule PSYCHIATRIC DIAGNOSTIC EVALUATION 90791_3 CDM 960 RC 90791 HCPCS outpatient 294 220.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 294 999999999 103.28 294 fee schedule PSYCHIATRIC DIAGNOSTIC EVALUATION 90791_3 CDM 960 RC 90791 HCPCS outpatient 294 220.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 294 999999999 103.28 294 fee schedule PSYCHIATRIC DIAGNOSTIC EVALUATION 90791_3 CDM 960 RC 90791 HCPCS outpatient 294 220.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 177.61 999999999 103.28 294 fee schedule PSYCHIATRIC DIAGNOSTIC EVALUATION 90791_3 CDM 960 RC 90791 HCPCS outpatient 294 220.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 178 999999999 103.28 294 fee schedule PSYCHIATRIC DIAGNOSTIC EVALUATION 90791_3 CDM 960 RC 90791 HCPCS outpatient 294 220.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 178 999999999 103.28 294 fee schedule PSYCHIATRIC DIAGNOSTIC EVALUATION 90791_3 CDM 960 RC 90791 HCPCS outpatient 294 220.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 294 999999999 103.28 294 fee schedule PSYCHIATRIC DIAGNOSTIC EVALUATION 90791_3 CDM 960 RC 90791 HCPCS outpatient 294 220.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 174.99 999999999 103.28 294 fee schedule PSYCHIATRIC DIAGNOSTIC EVALUATION 90791_3 CDM 960 RC 90791 HCPCS outpatient 294 220.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 294 999999999 103.28 294 fee schedule PSYCHIATRIC DIAGNOSTIC EVALUATION WITH MEDICAL SERVICES 90792_3 CDM 960 RC 90792 HCPCS outpatient 329 246.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 164.64 999999999 96.23 329 fee schedule PSYCHIATRIC DIAGNOSTIC EVALUATION WITH MEDICAL SERVICES 90792_3 CDM 960 RC 90792 HCPCS outpatient 329 246.75 AETNA MCR ADV AETNA MCR ADV 329 999999999 96.23 329 fee schedule PSYCHIATRIC DIAGNOSTIC EVALUATION WITH MEDICAL SERVICES 90792_3 CDM 960 RC 90792 HCPCS outpatient 329 246.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 101.04 999999999 96.23 329 fee schedule PSYCHIATRIC DIAGNOSTIC EVALUATION WITH MEDICAL SERVICES 90792_3 CDM 960 RC 90792 HCPCS outpatient 329 246.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 96.23 999999999 96.23 329 fee schedule PSYCHIATRIC DIAGNOSTIC EVALUATION WITH MEDICAL SERVICES 90792_3 CDM 960 RC 90792 HCPCS outpatient 329 246.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 329 999999999 96.23 329 fee schedule PSYCHIATRIC DIAGNOSTIC EVALUATION WITH MEDICAL SERVICES 90792_3 CDM 960 RC 90792 HCPCS outpatient 329 246.75 MOLINA MCAID MOLINA MCAID 101.04 999999999 96.23 329 fee schedule PSYCHIATRIC DIAGNOSTIC EVALUATION WITH MEDICAL SERVICES 90792_3 CDM 960 RC 90792 HCPCS outpatient 329 246.75 MOLINA MCR ADV MOLINA MCR ADV 329 999999999 96.23 329 fee schedule PSYCHIATRIC DIAGNOSTIC EVALUATION WITH MEDICAL SERVICES 90792_3 CDM 960 RC 90792 HCPCS outpatient 329 246.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 329 999999999 96.23 329 fee schedule PSYCHIATRIC DIAGNOSTIC EVALUATION WITH MEDICAL SERVICES 90792_3 CDM 960 RC 90792 HCPCS outpatient 329 246.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 329 999999999 96.23 329 fee schedule PSYCHIATRIC DIAGNOSTIC EVALUATION WITH MEDICAL SERVICES 90792_3 CDM 960 RC 90792 HCPCS outpatient 329 246.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 196.32 999999999 96.23 329 fee schedule PSYCHIATRIC DIAGNOSTIC EVALUATION WITH MEDICAL SERVICES 90792_3 CDM 960 RC 90792 HCPCS outpatient 329 246.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 200.5 999999999 96.23 329 fee schedule PSYCHIATRIC DIAGNOSTIC EVALUATION WITH MEDICAL SERVICES 90792_3 CDM 960 RC 90792 HCPCS outpatient 329 246.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 200.5 999999999 96.23 329 fee schedule PSYCHIATRIC DIAGNOSTIC EVALUATION WITH MEDICAL SERVICES 90792_3 CDM 960 RC 90792 HCPCS outpatient 329 246.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 329 999999999 96.23 329 fee schedule PSYCHIATRIC DIAGNOSTIC EVALUATION WITH MEDICAL SERVICES 90792_3 CDM 960 RC 90792 HCPCS outpatient 329 246.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 200.66 999999999 96.23 329 fee schedule PSYCHIATRIC DIAGNOSTIC EVALUATION WITH MEDICAL SERVICES 90792_3 CDM 960 RC 90792 HCPCS outpatient 329 246.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 329 999999999 96.23 329 fee schedule "PSYCHOTHERAPY, 30 MINUTES WITH PATIENT" 90832_3 CDM 960 RC 90832 HCPCS outpatient 128 96 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 71.17 999999999 47.73 128 fee schedule "PSYCHOTHERAPY, 30 MINUTES WITH PATIENT" 90832_3 CDM 960 RC 90832 HCPCS outpatient 128 96 AETNA MCR ADV AETNA MCR ADV 128 999999999 47.73 128 fee schedule "PSYCHOTHERAPY, 30 MINUTES WITH PATIENT" 90832_3 CDM 960 RC 90832 HCPCS outpatient 128 96 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50.12 999999999 47.73 128 fee schedule "PSYCHOTHERAPY, 30 MINUTES WITH PATIENT" 90832_3 CDM 960 RC 90832 HCPCS outpatient 128 96 COORDINATED CARE MCAID COORDINATED CARE MCAID 47.73 999999999 47.73 128 fee schedule "PSYCHOTHERAPY, 30 MINUTES WITH PATIENT" 90832_3 CDM 960 RC 90832 HCPCS outpatient 128 96 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 128 999999999 47.73 128 fee schedule "PSYCHOTHERAPY, 30 MINUTES WITH PATIENT" 90832_3 CDM 960 RC 90832 HCPCS outpatient 128 96 MOLINA MCAID MOLINA MCAID 50.12 999999999 47.73 128 fee schedule "PSYCHOTHERAPY, 30 MINUTES WITH PATIENT" 90832_3 CDM 960 RC 90832 HCPCS outpatient 128 96 MOLINA MCR ADV MOLINA MCR ADV 128 999999999 47.73 128 fee schedule "PSYCHOTHERAPY, 30 MINUTES WITH PATIENT" 90832_3 CDM 960 RC 90832 HCPCS outpatient 128 96 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 128 999999999 47.73 128 fee schedule "PSYCHOTHERAPY, 30 MINUTES WITH PATIENT" 90832_3 CDM 960 RC 90832 HCPCS outpatient 128 96 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 128 999999999 47.73 128 fee schedule "PSYCHOTHERAPY, 30 MINUTES WITH PATIENT" 90832_3 CDM 960 RC 90832 HCPCS outpatient 128 96 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 85.92 999999999 47.73 128 fee schedule "PSYCHOTHERAPY, 30 MINUTES WITH PATIENT" 90832_3 CDM 960 RC 90832 HCPCS outpatient 128 96 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 88.5 999999999 47.73 128 fee schedule "PSYCHOTHERAPY, 30 MINUTES WITH PATIENT" 90832_3 CDM 960 RC 90832 HCPCS outpatient 128 96 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 88.5 999999999 47.73 128 fee schedule "PSYCHOTHERAPY, 30 MINUTES WITH PATIENT" 90832_3 CDM 960 RC 90832 HCPCS outpatient 128 96 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 128 999999999 47.73 128 fee schedule "PSYCHOTHERAPY, 30 MINUTES WITH PATIENT" 90832_3 CDM 960 RC 90832 HCPCS outpatient 128 96 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 80.98 999999999 47.73 128 fee schedule "PSYCHOTHERAPY, 30 MINUTES WITH PATIENT" 90832_3 CDM 960 RC 90832 HCPCS outpatient 128 96 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 128 999999999 47.73 128 fee schedule "PSYCHOTHERAPY, 30 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90833_3 CDM 960 RC 90833 HCPCS outpatient 117 87.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 74.41 999999999 50.72 117 fee schedule "PSYCHOTHERAPY, 30 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90833_3 CDM 960 RC 90833 HCPCS outpatient 117 87.75 AETNA MCR ADV AETNA MCR ADV 117 999999999 50.72 117 fee schedule "PSYCHOTHERAPY, 30 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90833_3 CDM 960 RC 90833 HCPCS outpatient 117 87.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 53.26 999999999 50.72 117 fee schedule "PSYCHOTHERAPY, 30 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90833_3 CDM 960 RC 90833 HCPCS outpatient 117 87.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 50.72 999999999 50.72 117 fee schedule "PSYCHOTHERAPY, 30 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90833_3 CDM 960 RC 90833 HCPCS outpatient 117 87.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 117 999999999 50.72 117 fee schedule "PSYCHOTHERAPY, 30 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90833_3 CDM 960 RC 90833 HCPCS outpatient 117 87.75 MOLINA MCAID MOLINA MCAID 53.26 999999999 50.72 117 fee schedule "PSYCHOTHERAPY, 30 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90833_3 CDM 960 RC 90833 HCPCS outpatient 117 87.75 MOLINA MCR ADV MOLINA MCR ADV 117 999999999 50.72 117 fee schedule "PSYCHOTHERAPY, 30 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90833_3 CDM 960 RC 90833 HCPCS outpatient 117 87.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 117 999999999 50.72 117 fee schedule "PSYCHOTHERAPY, 30 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90833_3 CDM 960 RC 90833 HCPCS outpatient 117 87.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 117 999999999 50.72 117 fee schedule "PSYCHOTHERAPY, 30 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90833_3 CDM 960 RC 90833 HCPCS outpatient 117 87.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 88.8 999999999 50.72 117 fee schedule "PSYCHOTHERAPY, 30 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90833_3 CDM 960 RC 90833 HCPCS outpatient 117 87.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 92.5 999999999 50.72 117 fee schedule "PSYCHOTHERAPY, 30 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90833_3 CDM 960 RC 90833 HCPCS outpatient 117 87.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 92.5 999999999 50.72 117 fee schedule "PSYCHOTHERAPY, 30 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90833_3 CDM 960 RC 90833 HCPCS outpatient 117 87.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 117 999999999 50.72 117 fee schedule "PSYCHOTHERAPY, 30 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90833_3 CDM 960 RC 90833 HCPCS outpatient 117 87.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 75.84 999999999 50.72 117 fee schedule "PSYCHOTHERAPY, 30 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90833_3 CDM 960 RC 90833 HCPCS outpatient 117 87.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 117 999999999 50.72 117 fee schedule "PSYCHOTHERAPY, 45 MINUTES WITH PATIENT" 90834_3 CDM 960 RC 90834 HCPCS outpatient 169 126.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 117.01 999999999 72.75 169 fee schedule "PSYCHOTHERAPY, 45 MINUTES WITH PATIENT" 90834_3 CDM 960 RC 90834 HCPCS outpatient 169 126.75 AETNA MCR ADV AETNA MCR ADV 169 999999999 72.75 169 fee schedule "PSYCHOTHERAPY, 45 MINUTES WITH PATIENT" 90834_3 CDM 960 RC 90834 HCPCS outpatient 169 126.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 76.39 999999999 72.75 169 fee schedule "PSYCHOTHERAPY, 45 MINUTES WITH PATIENT" 90834_3 CDM 960 RC 90834 HCPCS outpatient 169 126.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 72.75 999999999 72.75 169 fee schedule "PSYCHOTHERAPY, 45 MINUTES WITH PATIENT" 90834_3 CDM 960 RC 90834 HCPCS outpatient 169 126.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 169 999999999 72.75 169 fee schedule "PSYCHOTHERAPY, 45 MINUTES WITH PATIENT" 90834_3 CDM 960 RC 90834 HCPCS outpatient 169 126.75 MOLINA MCAID MOLINA MCAID 76.39 999999999 72.75 169 fee schedule "PSYCHOTHERAPY, 45 MINUTES WITH PATIENT" 90834_3 CDM 960 RC 90834 HCPCS outpatient 169 126.75 MOLINA MCR ADV MOLINA MCR ADV 169 999999999 72.75 169 fee schedule "PSYCHOTHERAPY, 45 MINUTES WITH PATIENT" 90834_3 CDM 960 RC 90834 HCPCS outpatient 169 126.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 169 999999999 72.75 169 fee schedule "PSYCHOTHERAPY, 45 MINUTES WITH PATIENT" 90834_3 CDM 960 RC 90834 HCPCS outpatient 169 126.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 169 999999999 72.75 169 fee schedule "PSYCHOTHERAPY, 45 MINUTES WITH PATIENT" 90834_3 CDM 960 RC 90834 HCPCS outpatient 169 126.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 114.23 999999999 72.75 169 fee schedule "PSYCHOTHERAPY, 45 MINUTES WITH PATIENT" 90834_3 CDM 960 RC 90834 HCPCS outpatient 169 126.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 118 999999999 72.75 169 fee schedule "PSYCHOTHERAPY, 45 MINUTES WITH PATIENT" 90834_3 CDM 960 RC 90834 HCPCS outpatient 169 126.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 118 999999999 72.75 169 fee schedule "PSYCHOTHERAPY, 45 MINUTES WITH PATIENT" 90834_3 CDM 960 RC 90834 HCPCS outpatient 169 126.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 169 999999999 72.75 169 fee schedule "PSYCHOTHERAPY, 45 MINUTES WITH PATIENT" 90834_3 CDM 960 RC 90834 HCPCS outpatient 169 126.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 107.05 999999999 72.75 169 fee schedule "PSYCHOTHERAPY, 45 MINUTES WITH PATIENT" 90834_3 CDM 960 RC 90834 HCPCS outpatient 169 126.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 169 999999999 72.75 169 fee schedule "PSYCHOTHERAPY, 45 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90836_3 CDM 960 RC 90836 HCPCS outpatient 148 111 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 122.63 999999999 64.02 148 fee schedule "PSYCHOTHERAPY, 45 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90836_3 CDM 960 RC 90836 HCPCS outpatient 148 111 AETNA MCR ADV AETNA MCR ADV 148 999999999 64.02 148 fee schedule "PSYCHOTHERAPY, 45 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90836_3 CDM 960 RC 90836 HCPCS outpatient 148 111 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 67.22 999999999 64.02 148 fee schedule "PSYCHOTHERAPY, 45 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90836_3 CDM 960 RC 90836 HCPCS outpatient 148 111 COORDINATED CARE MCAID COORDINATED CARE MCAID 64.02 999999999 64.02 148 fee schedule "PSYCHOTHERAPY, 45 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90836_3 CDM 960 RC 90836 HCPCS outpatient 148 111 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 148 999999999 64.02 148 fee schedule "PSYCHOTHERAPY, 45 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90836_3 CDM 960 RC 90836 HCPCS outpatient 148 111 MOLINA MCAID MOLINA MCAID 67.22 999999999 64.02 148 fee schedule "PSYCHOTHERAPY, 45 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90836_3 CDM 960 RC 90836 HCPCS outpatient 148 111 MOLINA MCR ADV MOLINA MCR ADV 148 999999999 64.02 148 fee schedule "PSYCHOTHERAPY, 45 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90836_3 CDM 960 RC 90836 HCPCS outpatient 148 111 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 148 999999999 64.02 148 fee schedule "PSYCHOTHERAPY, 45 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90836_3 CDM 960 RC 90836 HCPCS outpatient 148 111 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 148 999999999 64.02 148 fee schedule "PSYCHOTHERAPY, 45 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90836_3 CDM 960 RC 90836 HCPCS outpatient 148 111 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 112.8 999999999 64.02 148 fee schedule "PSYCHOTHERAPY, 45 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90836_3 CDM 960 RC 90836 HCPCS outpatient 148 111 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 116.5 999999999 64.02 148 fee schedule "PSYCHOTHERAPY, 45 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90836_3 CDM 960 RC 90836 HCPCS outpatient 148 111 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 116.5 999999999 64.02 148 fee schedule "PSYCHOTHERAPY, 45 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90836_3 CDM 960 RC 90836 HCPCS outpatient 148 111 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 148 999999999 64.02 148 fee schedule "PSYCHOTHERAPY, 45 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90836_3 CDM 960 RC 90836 HCPCS outpatient 148 111 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 95.99 999999999 64.02 148 fee schedule "PSYCHOTHERAPY, 45 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90836_3 CDM 960 RC 90836 HCPCS outpatient 148 111 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 148 999999999 64.02 148 fee schedule "PSYCHOTHERAPY, 60 MINUTES WITH PATIENT" 90837_3 CDM 960 RC 90837 HCPCS outpatient 248 186 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 142.69 999999999 93.17 248 fee schedule "PSYCHOTHERAPY, 60 MINUTES WITH PATIENT" 90837_3 CDM 960 RC 90837 HCPCS outpatient 248 186 AETNA MCR ADV AETNA MCR ADV 248 999999999 93.17 248 fee schedule "PSYCHOTHERAPY, 60 MINUTES WITH PATIENT" 90837_3 CDM 960 RC 90837 HCPCS outpatient 248 186 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 97.83 999999999 93.17 248 fee schedule "PSYCHOTHERAPY, 60 MINUTES WITH PATIENT" 90837_3 CDM 960 RC 90837 HCPCS outpatient 248 186 COORDINATED CARE MCAID COORDINATED CARE MCAID 93.17 999999999 93.17 248 fee schedule "PSYCHOTHERAPY, 60 MINUTES WITH PATIENT" 90837_3 CDM 960 RC 90837 HCPCS outpatient 248 186 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 248 999999999 93.17 248 fee schedule "PSYCHOTHERAPY, 60 MINUTES WITH PATIENT" 90837_3 CDM 960 RC 90837 HCPCS outpatient 248 186 MOLINA MCAID MOLINA MCAID 97.83 999999999 93.17 248 fee schedule "PSYCHOTHERAPY, 60 MINUTES WITH PATIENT" 90837_3 CDM 960 RC 90837 HCPCS outpatient 248 186 MOLINA MCR ADV MOLINA MCR ADV 248 999999999 93.17 248 fee schedule "PSYCHOTHERAPY, 60 MINUTES WITH PATIENT" 90837_3 CDM 960 RC 90837 HCPCS outpatient 248 186 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 248 999999999 93.17 248 fee schedule "PSYCHOTHERAPY, 60 MINUTES WITH PATIENT" 90837_3 CDM 960 RC 90837 HCPCS outpatient 248 186 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 248 999999999 93.17 248 fee schedule "PSYCHOTHERAPY, 60 MINUTES WITH PATIENT" 90837_3 CDM 960 RC 90837 HCPCS outpatient 248 186 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 171.84 999999999 93.17 248 fee schedule "PSYCHOTHERAPY, 60 MINUTES WITH PATIENT" 90837_3 CDM 960 RC 90837 HCPCS outpatient 248 186 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 135.92 999999999 93.17 248 fee schedule "PSYCHOTHERAPY, 60 MINUTES WITH PATIENT" 90837_3 CDM 960 RC 90837 HCPCS outpatient 248 186 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 135.92 999999999 93.17 248 fee schedule "PSYCHOTHERAPY, 60 MINUTES WITH PATIENT" 90837_3 CDM 960 RC 90837 HCPCS outpatient 248 186 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 248 999999999 93.17 248 fee schedule "PSYCHOTHERAPY, 60 MINUTES WITH PATIENT" 90837_3 CDM 960 RC 90837 HCPCS outpatient 248 186 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 158 999999999 93.17 248 fee schedule "PSYCHOTHERAPY, 60 MINUTES WITH PATIENT" 90837_3 CDM 960 RC 90837 HCPCS outpatient 248 186 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 248 999999999 93.17 248 fee schedule "PSYCHOTHERAPY, 60 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90838_3 CDM 960 RC 90838 HCPCS outpatient 194 145.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 141.03 999999999 75.05 194 fee schedule "PSYCHOTHERAPY, 60 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90838_3 CDM 960 RC 90838 HCPCS outpatient 194 145.5 AETNA MCR ADV AETNA MCR ADV 194 999999999 75.05 194 fee schedule "PSYCHOTHERAPY, 60 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90838_3 CDM 960 RC 90838 HCPCS outpatient 194 145.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 78.8 999999999 75.05 194 fee schedule "PSYCHOTHERAPY, 60 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90838_3 CDM 960 RC 90838 HCPCS outpatient 194 145.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 75.05 999999999 75.05 194 fee schedule "PSYCHOTHERAPY, 60 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90838_3 CDM 960 RC 90838 HCPCS outpatient 194 145.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 194 999999999 75.05 194 fee schedule "PSYCHOTHERAPY, 60 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90838_3 CDM 960 RC 90838 HCPCS outpatient 194 145.5 MOLINA MCAID MOLINA MCAID 78.8 999999999 75.05 194 fee schedule "PSYCHOTHERAPY, 60 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90838_3 CDM 960 RC 90838 HCPCS outpatient 194 145.5 MOLINA MCR ADV MOLINA MCR ADV 194 999999999 75.05 194 fee schedule "PSYCHOTHERAPY, 60 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90838_3 CDM 960 RC 90838 HCPCS outpatient 194 145.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 194 999999999 75.05 194 fee schedule "PSYCHOTHERAPY, 60 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90838_3 CDM 960 RC 90838 HCPCS outpatient 194 145.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 194 999999999 75.05 194 fee schedule "PSYCHOTHERAPY, 60 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90838_3 CDM 960 RC 90838 HCPCS outpatient 194 145.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 148.8 999999999 75.05 194 fee schedule "PSYCHOTHERAPY, 60 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90838_3 CDM 960 RC 90838 HCPCS outpatient 194 145.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 154 999999999 75.05 194 fee schedule "PSYCHOTHERAPY, 60 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90838_3 CDM 960 RC 90838 HCPCS outpatient 194 145.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 154 999999999 75.05 194 fee schedule "PSYCHOTHERAPY, 60 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90838_3 CDM 960 RC 90838 HCPCS outpatient 194 145.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 194 999999999 75.05 194 fee schedule "PSYCHOTHERAPY, 60 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90838_3 CDM 960 RC 90838 HCPCS outpatient 194 145.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 127.19 999999999 75.05 194 fee schedule "PSYCHOTHERAPY, 60 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)" 90838_3 CDM 960 RC 90838 HCPCS outpatient 194 145.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 194 999999999 75.05 194 fee schedule "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 92950_1 CDM 480 RC 92950 HCPCS outpatient 550.38 412.79 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 495.34 90 999999999 429.3 522.86 percent of total billed charges "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 92950_1 CDM 480 RC 92950 HCPCS outpatient 550.38 412.79 AETNA MCR ADV AETNA MCR ADV 429.3 78 999999999 429.3 522.86 percent of total billed charges "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 92950_1 CDM 480 RC 92950 HCPCS outpatient 550.38 412.79 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 481.97 87.57 999999999 429.3 522.86 percent of total billed charges "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 92950_1 CDM 480 RC 92950 HCPCS outpatient 550.38 412.79 COORDINATED CARE MCAID COORDINATED CARE MCAID 468.21 85.07 999999999 429.3 522.86 percent of total billed charges "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 92950_1 CDM 480 RC 92950 HCPCS outpatient 550.38 412.79 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 468.21 85.07 999999999 429.3 522.86 percent of total billed charges "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 92950_1 CDM 480 RC 92950 HCPCS outpatient 550.38 412.79 MOLINA MCAID MOLINA MCAID 459.02 83.4 999999999 429.3 522.86 percent of total billed charges "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 92950_1 CDM 480 RC 92950 HCPCS outpatient 550.38 412.79 MOLINA MCR ADV MOLINA MCR ADV 489.84 89 999999999 429.3 522.86 percent of total billed charges "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 92950_1 CDM 480 RC 92950 HCPCS outpatient 550.38 412.79 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 489.84 89 999999999 429.3 522.86 percent of total billed charges "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 92950_1 CDM 480 RC 92950 HCPCS outpatient 550.38 412.79 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 489.84 89 999999999 429.3 522.86 percent of total billed charges "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 92950_1 CDM 480 RC 92950 HCPCS outpatient 550.38 412.79 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 495.34 90 999999999 429.3 522.86 percent of total billed charges "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 92950_1 CDM 480 RC 92950 HCPCS outpatient 550.38 412.79 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 522.86 95 999999999 429.3 522.86 percent of total billed charges "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 92950_1 CDM 480 RC 92950 HCPCS outpatient 550.38 412.79 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 522.86 95 999999999 429.3 522.86 percent of total billed charges "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 92950_1 CDM 480 RC 92950 HCPCS outpatient 550.38 412.79 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 489.84 89 999999999 429.3 522.86 percent of total billed charges "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 92950_1 CDM 480 RC 92950 HCPCS outpatient 550.38 412.79 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 484.33 88 999999999 429.3 522.86 percent of total billed charges "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 92950_1 CDM 480 RC 92950 HCPCS outpatient 550.38 412.79 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 489.84 89 999999999 429.3 522.86 percent of total billed charges "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 92950_2 CDM 480 RC 92950 HCPCS outpatient 550.38 412.79 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 495.34 90 999999999 429.3 522.86 percent of total billed charges "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 92950_2 CDM 480 RC 92950 HCPCS outpatient 550.38 412.79 AETNA MCR ADV AETNA MCR ADV 429.3 78 999999999 429.3 522.86 percent of total billed charges "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 92950_2 CDM 480 RC 92950 HCPCS outpatient 550.38 412.79 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 481.97 87.57 999999999 429.3 522.86 percent of total billed charges "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 92950_2 CDM 480 RC 92950 HCPCS outpatient 550.38 412.79 COORDINATED CARE MCAID COORDINATED CARE MCAID 468.21 85.07 999999999 429.3 522.86 percent of total billed charges "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 92950_2 CDM 480 RC 92950 HCPCS outpatient 550.38 412.79 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 468.21 85.07 999999999 429.3 522.86 percent of total billed charges "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 92950_2 CDM 480 RC 92950 HCPCS outpatient 550.38 412.79 MOLINA MCAID MOLINA MCAID 459.02 83.4 999999999 429.3 522.86 percent of total billed charges "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 92950_2 CDM 480 RC 92950 HCPCS outpatient 550.38 412.79 MOLINA MCR ADV MOLINA MCR ADV 489.84 89 999999999 429.3 522.86 percent of total billed charges "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 92950_2 CDM 480 RC 92950 HCPCS outpatient 550.38 412.79 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 489.84 89 999999999 429.3 522.86 percent of total billed charges "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 92950_2 CDM 480 RC 92950 HCPCS outpatient 550.38 412.79 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 489.84 89 999999999 429.3 522.86 percent of total billed charges "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 92950_2 CDM 480 RC 92950 HCPCS outpatient 550.38 412.79 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 495.34 90 999999999 429.3 522.86 percent of total billed charges "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 92950_2 CDM 480 RC 92950 HCPCS outpatient 550.38 412.79 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 522.86 95 999999999 429.3 522.86 percent of total billed charges "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 92950_2 CDM 480 RC 92950 HCPCS outpatient 550.38 412.79 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 522.86 95 999999999 429.3 522.86 percent of total billed charges "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 92950_2 CDM 480 RC 92950 HCPCS outpatient 550.38 412.79 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 489.84 89 999999999 429.3 522.86 percent of total billed charges "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 92950_2 CDM 480 RC 92950 HCPCS outpatient 550.38 412.79 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 484.33 88 999999999 429.3 522.86 percent of total billed charges "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 92950_2 CDM 480 RC 92950 HCPCS outpatient 550.38 412.79 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 489.84 89 999999999 429.3 522.86 percent of total billed charges "CARDIOVERSION, ELECTIVE, ELECTRICAL CONVERSION OF ARRHYTHMIA; EXTERNAL" 92960_1 CDM 480 RC 92960 HCPCS outpatient 325.83 244.37 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 293.25 90 999999999 254.15 309.54 percent of total billed charges "CARDIOVERSION, ELECTIVE, ELECTRICAL CONVERSION OF ARRHYTHMIA; EXTERNAL" 92960_1 CDM 480 RC 92960 HCPCS outpatient 325.83 244.37 AETNA MCR ADV AETNA MCR ADV 254.15 78 999999999 254.15 309.54 percent of total billed charges "CARDIOVERSION, ELECTIVE, ELECTRICAL CONVERSION OF ARRHYTHMIA; EXTERNAL" 92960_1 CDM 480 RC 92960 HCPCS outpatient 325.83 244.37 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 285.33 87.57 999999999 254.15 309.54 percent of total billed charges "CARDIOVERSION, ELECTIVE, ELECTRICAL CONVERSION OF ARRHYTHMIA; EXTERNAL" 92960_1 CDM 480 RC 92960 HCPCS outpatient 325.83 244.37 COORDINATED CARE MCAID COORDINATED CARE MCAID 277.18 85.07 999999999 254.15 309.54 percent of total billed charges "CARDIOVERSION, ELECTIVE, ELECTRICAL CONVERSION OF ARRHYTHMIA; EXTERNAL" 92960_1 CDM 480 RC 92960 HCPCS outpatient 325.83 244.37 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 277.18 85.07 999999999 254.15 309.54 percent of total billed charges "CARDIOVERSION, ELECTIVE, ELECTRICAL CONVERSION OF ARRHYTHMIA; EXTERNAL" 92960_1 CDM 480 RC 92960 HCPCS outpatient 325.83 244.37 MOLINA MCAID MOLINA MCAID 271.74 83.4 999999999 254.15 309.54 percent of total billed charges "CARDIOVERSION, ELECTIVE, ELECTRICAL CONVERSION OF ARRHYTHMIA; EXTERNAL" 92960_1 CDM 480 RC 92960 HCPCS outpatient 325.83 244.37 MOLINA MCR ADV MOLINA MCR ADV 289.99 89 999999999 254.15 309.54 percent of total billed charges "CARDIOVERSION, ELECTIVE, ELECTRICAL CONVERSION OF ARRHYTHMIA; EXTERNAL" 92960_1 CDM 480 RC 92960 HCPCS outpatient 325.83 244.37 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 289.99 89 999999999 254.15 309.54 percent of total billed charges "CARDIOVERSION, ELECTIVE, ELECTRICAL CONVERSION OF ARRHYTHMIA; EXTERNAL" 92960_1 CDM 480 RC 92960 HCPCS outpatient 325.83 244.37 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 289.99 89 999999999 254.15 309.54 percent of total billed charges "CARDIOVERSION, ELECTIVE, ELECTRICAL CONVERSION OF ARRHYTHMIA; EXTERNAL" 92960_1 CDM 480 RC 92960 HCPCS outpatient 325.83 244.37 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 293.25 90 999999999 254.15 309.54 percent of total billed charges "CARDIOVERSION, ELECTIVE, ELECTRICAL CONVERSION OF ARRHYTHMIA; EXTERNAL" 92960_1 CDM 480 RC 92960 HCPCS outpatient 325.83 244.37 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 309.54 95 999999999 254.15 309.54 percent of total billed charges "CARDIOVERSION, ELECTIVE, ELECTRICAL CONVERSION OF ARRHYTHMIA; EXTERNAL" 92960_1 CDM 480 RC 92960 HCPCS outpatient 325.83 244.37 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 309.54 95 999999999 254.15 309.54 percent of total billed charges "CARDIOVERSION, ELECTIVE, ELECTRICAL CONVERSION OF ARRHYTHMIA; EXTERNAL" 92960_1 CDM 480 RC 92960 HCPCS outpatient 325.83 244.37 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 289.99 89 999999999 254.15 309.54 percent of total billed charges "CARDIOVERSION, ELECTIVE, ELECTRICAL CONVERSION OF ARRHYTHMIA; EXTERNAL" 92960_1 CDM 480 RC 92960 HCPCS outpatient 325.83 244.37 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 286.73 88 999999999 254.15 309.54 percent of total billed charges "CARDIOVERSION, ELECTIVE, ELECTRICAL CONVERSION OF ARRHYTHMIA; EXTERNAL" 92960_1 CDM 480 RC 92960 HCPCS outpatient 325.83 244.37 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 289.99 89 999999999 254.15 309.54 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT" 93005_2 CDM 730 RC 93005 HCPCS outpatient 228 171 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 205.2 90 999999999 177.84 216.6 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT" 93005_2 CDM 730 RC 93005 HCPCS outpatient 228 171 AETNA MCR ADV AETNA MCR ADV 177.84 78 999999999 177.84 216.6 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT" 93005_2 CDM 730 RC 93005 HCPCS outpatient 228 171 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 199.66 87.57 999999999 177.84 216.6 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT" 93005_2 CDM 730 RC 93005 HCPCS outpatient 228 171 COORDINATED CARE MCAID COORDINATED CARE MCAID 193.96 85.07 999999999 177.84 216.6 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT" 93005_2 CDM 730 RC 93005 HCPCS outpatient 228 171 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 193.96 85.07 999999999 177.84 216.6 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT" 93005_2 CDM 730 RC 93005 HCPCS outpatient 228 171 MOLINA MCAID MOLINA MCAID 190.15 83.4 999999999 177.84 216.6 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT" 93005_2 CDM 730 RC 93005 HCPCS outpatient 228 171 MOLINA MCR ADV MOLINA MCR ADV 202.92 89 999999999 177.84 216.6 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT" 93005_2 CDM 730 RC 93005 HCPCS outpatient 228 171 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 202.92 89 999999999 177.84 216.6 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT" 93005_2 CDM 730 RC 93005 HCPCS outpatient 228 171 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 202.92 89 999999999 177.84 216.6 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT" 93005_2 CDM 730 RC 93005 HCPCS outpatient 228 171 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 205.2 90 999999999 177.84 216.6 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT" 93005_2 CDM 730 RC 93005 HCPCS outpatient 228 171 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 216.6 95 999999999 177.84 216.6 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT" 93005_2 CDM 730 RC 93005 HCPCS outpatient 228 171 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 216.6 95 999999999 177.84 216.6 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT" 93005_2 CDM 730 RC 93005 HCPCS outpatient 228 171 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 202.92 89 999999999 177.84 216.6 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT" 93005_2 CDM 730 RC 93005 HCPCS outpatient 228 171 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 200.64 88 999999999 177.84 216.6 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT" 93005_2 CDM 730 RC 93005 HCPCS outpatient 228 171 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 202.92 89 999999999 177.84 216.6 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; INTERPRETATION AND REPORT ONLY" 93010_1 CDM 730 RC 93010 HCPCS outpatient 94 70.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 84.6 90 999999999 73.32 89.3 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; INTERPRETATION AND REPORT ONLY" 93010_1 CDM 730 RC 93010 HCPCS outpatient 94 70.5 AETNA MCR ADV AETNA MCR ADV 73.32 78 999999999 73.32 89.3 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; INTERPRETATION AND REPORT ONLY" 93010_1 CDM 730 RC 93010 HCPCS outpatient 94 70.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 82.32 87.57 999999999 73.32 89.3 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; INTERPRETATION AND REPORT ONLY" 93010_1 CDM 730 RC 93010 HCPCS outpatient 94 70.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 79.97 85.07 999999999 73.32 89.3 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; INTERPRETATION AND REPORT ONLY" 93010_1 CDM 730 RC 93010 HCPCS outpatient 94 70.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 79.97 85.07 999999999 73.32 89.3 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; INTERPRETATION AND REPORT ONLY" 93010_1 CDM 730 RC 93010 HCPCS outpatient 94 70.5 MOLINA MCAID MOLINA MCAID 78.4 83.4 999999999 73.32 89.3 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; INTERPRETATION AND REPORT ONLY" 93010_1 CDM 730 RC 93010 HCPCS outpatient 94 70.5 MOLINA MCR ADV MOLINA MCR ADV 83.66 89 999999999 73.32 89.3 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; INTERPRETATION AND REPORT ONLY" 93010_1 CDM 730 RC 93010 HCPCS outpatient 94 70.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 83.66 89 999999999 73.32 89.3 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; INTERPRETATION AND REPORT ONLY" 93010_1 CDM 730 RC 93010 HCPCS outpatient 94 70.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 83.66 89 999999999 73.32 89.3 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; INTERPRETATION AND REPORT ONLY" 93010_1 CDM 730 RC 93010 HCPCS outpatient 94 70.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 84.6 90 999999999 73.32 89.3 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; INTERPRETATION AND REPORT ONLY" 93010_1 CDM 730 RC 93010 HCPCS outpatient 94 70.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 89.3 95 999999999 73.32 89.3 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; INTERPRETATION AND REPORT ONLY" 93010_1 CDM 730 RC 93010 HCPCS outpatient 94 70.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 89.3 95 999999999 73.32 89.3 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; INTERPRETATION AND REPORT ONLY" 93010_1 CDM 730 RC 93010 HCPCS outpatient 94 70.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 83.66 89 999999999 73.32 89.3 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; INTERPRETATION AND REPORT ONLY" 93010_1 CDM 730 RC 93010 HCPCS outpatient 94 70.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 82.72 88 999999999 73.32 89.3 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; INTERPRETATION AND REPORT ONLY" 93010_1 CDM 730 RC 93010 HCPCS outpatient 94 70.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 83.66 89 999999999 73.32 89.3 percent of total billed charges "EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CONTINUOUS RHYTHM RECORDING AND STORAGE; RECORDING (INCLUDES CONNECTION, RECORDING, AND DISCONNECTION)" 93225_1 CDM 730 RC 93225 HCPCS outpatient 59.73 44.8 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 53.76 90 999999999 46.59 56.74 percent of total billed charges "EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CONTINUOUS RHYTHM RECORDING AND STORAGE; RECORDING (INCLUDES CONNECTION, RECORDING, AND DISCONNECTION)" 93225_1 CDM 730 RC 93225 HCPCS outpatient 59.73 44.8 AETNA MCR ADV AETNA MCR ADV 46.59 78 999999999 46.59 56.74 percent of total billed charges "EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CONTINUOUS RHYTHM RECORDING AND STORAGE; RECORDING (INCLUDES CONNECTION, RECORDING, AND DISCONNECTION)" 93225_1 CDM 730 RC 93225 HCPCS outpatient 59.73 44.8 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 52.31 87.57 999999999 46.59 56.74 percent of total billed charges "EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CONTINUOUS RHYTHM RECORDING AND STORAGE; RECORDING (INCLUDES CONNECTION, RECORDING, AND DISCONNECTION)" 93225_1 CDM 730 RC 93225 HCPCS outpatient 59.73 44.8 COORDINATED CARE MCAID COORDINATED CARE MCAID 50.81 85.07 999999999 46.59 56.74 percent of total billed charges "EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CONTINUOUS RHYTHM RECORDING AND STORAGE; RECORDING (INCLUDES CONNECTION, RECORDING, AND DISCONNECTION)" 93225_1 CDM 730 RC 93225 HCPCS outpatient 59.73 44.8 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50.81 85.07 999999999 46.59 56.74 percent of total billed charges "EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CONTINUOUS RHYTHM RECORDING AND STORAGE; RECORDING (INCLUDES CONNECTION, RECORDING, AND DISCONNECTION)" 93225_1 CDM 730 RC 93225 HCPCS outpatient 59.73 44.8 MOLINA MCAID MOLINA MCAID 49.81 83.4 999999999 46.59 56.74 percent of total billed charges "EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CONTINUOUS RHYTHM RECORDING AND STORAGE; RECORDING (INCLUDES CONNECTION, RECORDING, AND DISCONNECTION)" 93225_1 CDM 730 RC 93225 HCPCS outpatient 59.73 44.8 MOLINA MCR ADV MOLINA MCR ADV 53.16 89 999999999 46.59 56.74 percent of total billed charges "EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CONTINUOUS RHYTHM RECORDING AND STORAGE; RECORDING (INCLUDES CONNECTION, RECORDING, AND DISCONNECTION)" 93225_1 CDM 730 RC 93225 HCPCS outpatient 59.73 44.8 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 53.16 89 999999999 46.59 56.74 percent of total billed charges "EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CONTINUOUS RHYTHM RECORDING AND STORAGE; RECORDING (INCLUDES CONNECTION, RECORDING, AND DISCONNECTION)" 93225_1 CDM 730 RC 93225 HCPCS outpatient 59.73 44.8 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 53.16 89 999999999 46.59 56.74 percent of total billed charges "EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CONTINUOUS RHYTHM RECORDING AND STORAGE; RECORDING (INCLUDES CONNECTION, RECORDING, AND DISCONNECTION)" 93225_1 CDM 730 RC 93225 HCPCS outpatient 59.73 44.8 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 53.76 90 999999999 46.59 56.74 percent of total billed charges "EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CONTINUOUS RHYTHM RECORDING AND STORAGE; RECORDING (INCLUDES CONNECTION, RECORDING, AND DISCONNECTION)" 93225_1 CDM 730 RC 93225 HCPCS outpatient 59.73 44.8 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 56.74 95 999999999 46.59 56.74 percent of total billed charges "EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CONTINUOUS RHYTHM RECORDING AND STORAGE; RECORDING (INCLUDES CONNECTION, RECORDING, AND DISCONNECTION)" 93225_1 CDM 730 RC 93225 HCPCS outpatient 59.73 44.8 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 56.74 95 999999999 46.59 56.74 percent of total billed charges "EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CONTINUOUS RHYTHM RECORDING AND STORAGE; RECORDING (INCLUDES CONNECTION, RECORDING, AND DISCONNECTION)" 93225_1 CDM 730 RC 93225 HCPCS outpatient 59.73 44.8 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 53.16 89 999999999 46.59 56.74 percent of total billed charges "EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CONTINUOUS RHYTHM RECORDING AND STORAGE; RECORDING (INCLUDES CONNECTION, RECORDING, AND DISCONNECTION)" 93225_1 CDM 730 RC 93225 HCPCS outpatient 59.73 44.8 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 52.56 88 999999999 46.59 56.74 percent of total billed charges "EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CONTINUOUS RHYTHM RECORDING AND STORAGE; RECORDING (INCLUDES CONNECTION, RECORDING, AND DISCONNECTION)" 93225_1 CDM 730 RC 93225 HCPCS outpatient 59.73 44.8 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 53.16 89 999999999 46.59 56.74 percent of total billed charges "BRONCHODILATION RESPONSIVENESS, SPIROMETRY AS IN 94010, PRE- AND POST-BRONCHODILATOR ADMINISTRATION" 94060_3 CDM 460 RC 94060 HCPCS outpatient 80 60 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 72 90 999999999 62.4 76 percent of total billed charges "BRONCHODILATION RESPONSIVENESS, SPIROMETRY AS IN 94010, PRE- AND POST-BRONCHODILATOR ADMINISTRATION" 94060_3 CDM 460 RC 94060 HCPCS outpatient 80 60 AETNA MCR ADV AETNA MCR ADV 62.4 78 999999999 62.4 76 percent of total billed charges "BRONCHODILATION RESPONSIVENESS, SPIROMETRY AS IN 94010, PRE- AND POST-BRONCHODILATOR ADMINISTRATION" 94060_3 CDM 460 RC 94060 HCPCS outpatient 80 60 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 70.06 87.57 999999999 62.4 76 percent of total billed charges "BRONCHODILATION RESPONSIVENESS, SPIROMETRY AS IN 94010, PRE- AND POST-BRONCHODILATOR ADMINISTRATION" 94060_3 CDM 460 RC 94060 HCPCS outpatient 80 60 COORDINATED CARE MCAID COORDINATED CARE MCAID 68.06 85.07 999999999 62.4 76 percent of total billed charges "BRONCHODILATION RESPONSIVENESS, SPIROMETRY AS IN 94010, PRE- AND POST-BRONCHODILATOR ADMINISTRATION" 94060_3 CDM 460 RC 94060 HCPCS outpatient 80 60 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 68.06 85.07 999999999 62.4 76 percent of total billed charges "BRONCHODILATION RESPONSIVENESS, SPIROMETRY AS IN 94010, PRE- AND POST-BRONCHODILATOR ADMINISTRATION" 94060_3 CDM 460 RC 94060 HCPCS outpatient 80 60 MOLINA MCAID MOLINA MCAID 66.72 83.4 999999999 62.4 76 percent of total billed charges "BRONCHODILATION RESPONSIVENESS, SPIROMETRY AS IN 94010, PRE- AND POST-BRONCHODILATOR ADMINISTRATION" 94060_3 CDM 460 RC 94060 HCPCS outpatient 80 60 MOLINA MCR ADV MOLINA MCR ADV 71.2 89 999999999 62.4 76 percent of total billed charges "BRONCHODILATION RESPONSIVENESS, SPIROMETRY AS IN 94010, PRE- AND POST-BRONCHODILATOR ADMINISTRATION" 94060_3 CDM 460 RC 94060 HCPCS outpatient 80 60 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 71.2 89 999999999 62.4 76 percent of total billed charges "BRONCHODILATION RESPONSIVENESS, SPIROMETRY AS IN 94010, PRE- AND POST-BRONCHODILATOR ADMINISTRATION" 94060_3 CDM 460 RC 94060 HCPCS outpatient 80 60 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 71.2 89 999999999 62.4 76 percent of total billed charges "BRONCHODILATION RESPONSIVENESS, SPIROMETRY AS IN 94010, PRE- AND POST-BRONCHODILATOR ADMINISTRATION" 94060_3 CDM 460 RC 94060 HCPCS outpatient 80 60 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 72 90 999999999 62.4 76 percent of total billed charges "BRONCHODILATION RESPONSIVENESS, SPIROMETRY AS IN 94010, PRE- AND POST-BRONCHODILATOR ADMINISTRATION" 94060_3 CDM 460 RC 94060 HCPCS outpatient 80 60 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 76 95 999999999 62.4 76 percent of total billed charges "BRONCHODILATION RESPONSIVENESS, SPIROMETRY AS IN 94010, PRE- AND POST-BRONCHODILATOR ADMINISTRATION" 94060_3 CDM 460 RC 94060 HCPCS outpatient 80 60 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 76 95 999999999 62.4 76 percent of total billed charges "BRONCHODILATION RESPONSIVENESS, SPIROMETRY AS IN 94010, PRE- AND POST-BRONCHODILATOR ADMINISTRATION" 94060_3 CDM 460 RC 94060 HCPCS outpatient 80 60 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 71.2 89 999999999 62.4 76 percent of total billed charges "BRONCHODILATION RESPONSIVENESS, SPIROMETRY AS IN 94010, PRE- AND POST-BRONCHODILATOR ADMINISTRATION" 94060_3 CDM 460 RC 94060 HCPCS outpatient 80 60 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 70.4 88 999999999 62.4 76 percent of total billed charges "BRONCHODILATION RESPONSIVENESS, SPIROMETRY AS IN 94010, PRE- AND POST-BRONCHODILATOR ADMINISTRATION" 94060_3 CDM 460 RC 94060 HCPCS outpatient 80 60 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 71.2 89 999999999 62.4 76 percent of total billed charges "MAXIMUM BREATHING CAPACITY, MAXIMAL VOLUNTARY VENTILATION" 94200_3 CDM 960 RC 94200 HCPCS outpatient 30 22.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 4.87 999999999 3.66 30 fee schedule "MAXIMUM BREATHING CAPACITY, MAXIMAL VOLUNTARY VENTILATION" 94200_3 CDM 960 RC 94200 HCPCS outpatient 30 22.5 AETNA MCR ADV AETNA MCR ADV 30 999999999 3.66 30 fee schedule "MAXIMUM BREATHING CAPACITY, MAXIMAL VOLUNTARY VENTILATION" 94200_3 CDM 960 RC 94200 HCPCS outpatient 30 22.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 9.4 999999999 3.66 30 fee schedule "MAXIMUM BREATHING CAPACITY, MAXIMAL VOLUNTARY VENTILATION" 94200_3 CDM 960 RC 94200 HCPCS outpatient 30 22.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 8.95 999999999 3.66 30 fee schedule "MAXIMUM BREATHING CAPACITY, MAXIMAL VOLUNTARY VENTILATION" 94200_3 CDM 960 RC 94200 HCPCS outpatient 30 22.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 30 999999999 3.66 30 fee schedule "MAXIMUM BREATHING CAPACITY, MAXIMAL VOLUNTARY VENTILATION" 94200_3 CDM 960 RC 94200 HCPCS outpatient 30 22.5 MOLINA MCAID MOLINA MCAID 9.4 999999999 3.66 30 fee schedule "MAXIMUM BREATHING CAPACITY, MAXIMAL VOLUNTARY VENTILATION" 94200_3 CDM 960 RC 94200 HCPCS outpatient 30 22.5 MOLINA MCR ADV MOLINA MCR ADV 30 999999999 3.66 30 fee schedule "MAXIMUM BREATHING CAPACITY, MAXIMAL VOLUNTARY VENTILATION" 94200_3 CDM 960 RC 94200 HCPCS outpatient 30 22.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 30 999999999 3.66 30 fee schedule "MAXIMUM BREATHING CAPACITY, MAXIMAL VOLUNTARY VENTILATION" 94200_3 CDM 960 RC 94200 HCPCS outpatient 30 22.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 30 999999999 3.66 30 fee schedule "MAXIMUM BREATHING CAPACITY, MAXIMAL VOLUNTARY VENTILATION" 94200_3 CDM 960 RC 94200 HCPCS outpatient 30 22.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 7.68 999999999 3.66 30 fee schedule "MAXIMUM BREATHING CAPACITY, MAXIMAL VOLUNTARY VENTILATION" 94200_3 CDM 960 RC 94200 HCPCS outpatient 30 22.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 8 999999999 3.66 30 fee schedule "MAXIMUM BREATHING CAPACITY, MAXIMAL VOLUNTARY VENTILATION" 94200_3 CDM 960 RC 94200 HCPCS outpatient 30 22.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 8 999999999 3.66 30 fee schedule "MAXIMUM BREATHING CAPACITY, MAXIMAL VOLUNTARY VENTILATION" 94200_3 CDM 960 RC 94200 HCPCS outpatient 30 22.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 30 999999999 3.66 30 fee schedule "MAXIMUM BREATHING CAPACITY, MAXIMAL VOLUNTARY VENTILATION" 94200_3 CDM 960 RC 94200 HCPCS outpatient 30 22.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 3.66 999999999 3.66 30 fee schedule "MAXIMUM BREATHING CAPACITY, MAXIMAL VOLUNTARY VENTILATION" 94200_3 CDM 960 RC 94200 HCPCS outpatient 30 22.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 30 999999999 3.66 30 fee schedule "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 94640_2 CDM 920 RC 94640 HCPCS outpatient 375 281.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 337.5 90 999999999 292.5 356.25 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 94640_2 CDM 920 RC 94640 HCPCS outpatient 375 281.25 AETNA MCR ADV AETNA MCR ADV 292.5 78 999999999 292.5 356.25 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 94640_2 CDM 920 RC 94640 HCPCS outpatient 375 281.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 328.39 87.57 999999999 292.5 356.25 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 94640_2 CDM 920 RC 94640 HCPCS outpatient 375 281.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 319.01 85.07 999999999 292.5 356.25 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 94640_2 CDM 920 RC 94640 HCPCS outpatient 375 281.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 319.01 85.07 999999999 292.5 356.25 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 94640_2 CDM 920 RC 94640 HCPCS outpatient 375 281.25 MOLINA MCAID MOLINA MCAID 312.75 83.4 999999999 292.5 356.25 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 94640_2 CDM 920 RC 94640 HCPCS outpatient 375 281.25 MOLINA MCR ADV MOLINA MCR ADV 333.75 89 999999999 292.5 356.25 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 94640_2 CDM 920 RC 94640 HCPCS outpatient 375 281.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 333.75 89 999999999 292.5 356.25 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 94640_2 CDM 920 RC 94640 HCPCS outpatient 375 281.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 333.75 89 999999999 292.5 356.25 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 94640_2 CDM 920 RC 94640 HCPCS outpatient 375 281.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 337.5 90 999999999 292.5 356.25 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 94640_2 CDM 920 RC 94640 HCPCS outpatient 375 281.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 356.25 95 999999999 292.5 356.25 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 94640_2 CDM 920 RC 94640 HCPCS outpatient 375 281.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 356.25 95 999999999 292.5 356.25 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 94640_2 CDM 920 RC 94640 HCPCS outpatient 375 281.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 333.75 89 999999999 292.5 356.25 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 94640_2 CDM 920 RC 94640 HCPCS outpatient 375 281.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 330 88 999999999 292.5 356.25 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 94640_2 CDM 920 RC 94640 HCPCS outpatient 375 281.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 333.75 89 999999999 292.5 356.25 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 94640_3 CDM 920 RC 94640 HCPCS outpatient 23 17.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 20.7 90 999999999 17.94 21.85 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 94640_3 CDM 920 RC 94640 HCPCS outpatient 23 17.25 AETNA MCR ADV AETNA MCR ADV 17.94 78 999999999 17.94 21.85 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 94640_3 CDM 920 RC 94640 HCPCS outpatient 23 17.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 20.14 87.57 999999999 17.94 21.85 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 94640_3 CDM 920 RC 94640 HCPCS outpatient 23 17.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 19.57 85.07 999999999 17.94 21.85 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 94640_3 CDM 920 RC 94640 HCPCS outpatient 23 17.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 19.57 85.07 999999999 17.94 21.85 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 94640_3 CDM 920 RC 94640 HCPCS outpatient 23 17.25 MOLINA MCAID MOLINA MCAID 19.18 83.4 999999999 17.94 21.85 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 94640_3 CDM 920 RC 94640 HCPCS outpatient 23 17.25 MOLINA MCR ADV MOLINA MCR ADV 20.47 89 999999999 17.94 21.85 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 94640_3 CDM 920 RC 94640 HCPCS outpatient 23 17.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 20.47 89 999999999 17.94 21.85 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 94640_3 CDM 920 RC 94640 HCPCS outpatient 23 17.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 20.47 89 999999999 17.94 21.85 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 94640_3 CDM 920 RC 94640 HCPCS outpatient 23 17.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 20.7 90 999999999 17.94 21.85 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 94640_3 CDM 920 RC 94640 HCPCS outpatient 23 17.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 21.85 95 999999999 17.94 21.85 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 94640_3 CDM 920 RC 94640 HCPCS outpatient 23 17.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 21.85 95 999999999 17.94 21.85 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 94640_3 CDM 920 RC 94640 HCPCS outpatient 23 17.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 20.47 89 999999999 17.94 21.85 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 94640_3 CDM 920 RC 94640 HCPCS outpatient 23 17.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 20.24 88 999999999 17.94 21.85 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 94640_3 CDM 920 RC 94640 HCPCS outpatient 23 17.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 20.47 89 999999999 17.94 21.85 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9510032_1 CDM 761 RC 51701 HCPCS outpatient 220 165 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 198 999999999 171.6 209 case rate "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9510032_1 CDM 761 RC 51701 HCPCS outpatient 220 165 AETNA MCR ADV AETNA MCR ADV 171.6 78 999999999 171.6 209 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9510032_1 CDM 761 RC 51701 HCPCS outpatient 220 165 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 192.65 87.57 999999999 171.6 209 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9510032_1 CDM 761 RC 51701 HCPCS outpatient 220 165 COORDINATED CARE MCAID COORDINATED CARE MCAID 187.15 85.07 999999999 171.6 209 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9510032_1 CDM 761 RC 51701 HCPCS outpatient 220 165 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 187.15 85.07 999999999 171.6 209 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9510032_1 CDM 761 RC 51701 HCPCS outpatient 220 165 MOLINA MCAID MOLINA MCAID 183.48 83.4 999999999 171.6 209 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9510032_1 CDM 761 RC 51701 HCPCS outpatient 220 165 MOLINA MCR ADV MOLINA MCR ADV 195.8 89 999999999 171.6 209 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9510032_1 CDM 761 RC 51701 HCPCS outpatient 220 165 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 195.8 89 999999999 171.6 209 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9510032_1 CDM 761 RC 51701 HCPCS outpatient 220 165 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 195.8 89 999999999 171.6 209 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9510032_1 CDM 761 RC 51701 HCPCS outpatient 220 165 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 198 90 999999999 171.6 209 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9510032_1 CDM 761 RC 51701 HCPCS outpatient 220 165 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 209 95 999999999 171.6 209 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9510032_1 CDM 761 RC 51701 HCPCS outpatient 220 165 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 209 95 999999999 171.6 209 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9510032_1 CDM 761 RC 51701 HCPCS outpatient 220 165 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 195.8 89 999999999 171.6 209 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9510032_1 CDM 761 RC 51701 HCPCS outpatient 220 165 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 193.6 88 999999999 171.6 209 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9510032_1 CDM 761 RC 51701 HCPCS outpatient 220 165 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 195.8 89 999999999 171.6 209 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 9510033_1 CDM 761 RC 51702 HCPCS outpatient 265 198.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 238.5 999999999 206.7 251.75 case rate "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 9510033_1 CDM 761 RC 51702 HCPCS outpatient 265 198.75 AETNA MCR ADV AETNA MCR ADV 206.7 78 999999999 206.7 251.75 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 9510033_1 CDM 761 RC 51702 HCPCS outpatient 265 198.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 232.06 87.57 999999999 206.7 251.75 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 9510033_1 CDM 761 RC 51702 HCPCS outpatient 265 198.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 225.44 85.07 999999999 206.7 251.75 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 9510033_1 CDM 761 RC 51702 HCPCS outpatient 265 198.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 225.44 85.07 999999999 206.7 251.75 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 9510033_1 CDM 761 RC 51702 HCPCS outpatient 265 198.75 MOLINA MCAID MOLINA MCAID 221.01 83.4 999999999 206.7 251.75 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 9510033_1 CDM 761 RC 51702 HCPCS outpatient 265 198.75 MOLINA MCR ADV MOLINA MCR ADV 235.85 89 999999999 206.7 251.75 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 9510033_1 CDM 761 RC 51702 HCPCS outpatient 265 198.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 235.85 89 999999999 206.7 251.75 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 9510033_1 CDM 761 RC 51702 HCPCS outpatient 265 198.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 235.85 89 999999999 206.7 251.75 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 9510033_1 CDM 761 RC 51702 HCPCS outpatient 265 198.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 238.5 90 999999999 206.7 251.75 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 9510033_1 CDM 761 RC 51702 HCPCS outpatient 265 198.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 251.75 95 999999999 206.7 251.75 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 9510033_1 CDM 761 RC 51702 HCPCS outpatient 265 198.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 251.75 95 999999999 206.7 251.75 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 9510033_1 CDM 761 RC 51702 HCPCS outpatient 265 198.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 235.85 89 999999999 206.7 251.75 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 9510033_1 CDM 761 RC 51702 HCPCS outpatient 265 198.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 233.2 88 999999999 206.7 251.75 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 9510033_1 CDM 761 RC 51702 HCPCS outpatient 265 198.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 235.85 89 999999999 206.7 251.75 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 9510033_2 CDM 761 RC 51702 HCPCS outpatient 265 198.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 238.5 999999999 206.7 251.75 case rate "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 9510033_2 CDM 761 RC 51702 HCPCS outpatient 265 198.75 AETNA MCR ADV AETNA MCR ADV 206.7 78 999999999 206.7 251.75 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 9510033_2 CDM 761 RC 51702 HCPCS outpatient 265 198.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 232.06 87.57 999999999 206.7 251.75 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 9510033_2 CDM 761 RC 51702 HCPCS outpatient 265 198.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 225.44 85.07 999999999 206.7 251.75 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 9510033_2 CDM 761 RC 51702 HCPCS outpatient 265 198.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 225.44 85.07 999999999 206.7 251.75 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 9510033_2 CDM 761 RC 51702 HCPCS outpatient 265 198.75 MOLINA MCAID MOLINA MCAID 221.01 83.4 999999999 206.7 251.75 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 9510033_2 CDM 761 RC 51702 HCPCS outpatient 265 198.75 MOLINA MCR ADV MOLINA MCR ADV 235.85 89 999999999 206.7 251.75 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 9510033_2 CDM 761 RC 51702 HCPCS outpatient 265 198.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 235.85 89 999999999 206.7 251.75 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 9510033_2 CDM 761 RC 51702 HCPCS outpatient 265 198.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 235.85 89 999999999 206.7 251.75 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 9510033_2 CDM 761 RC 51702 HCPCS outpatient 265 198.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 238.5 90 999999999 206.7 251.75 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 9510033_2 CDM 761 RC 51702 HCPCS outpatient 265 198.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 251.75 95 999999999 206.7 251.75 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 9510033_2 CDM 761 RC 51702 HCPCS outpatient 265 198.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 251.75 95 999999999 206.7 251.75 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 9510033_2 CDM 761 RC 51702 HCPCS outpatient 265 198.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 235.85 89 999999999 206.7 251.75 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 9510033_2 CDM 761 RC 51702 HCPCS outpatient 265 198.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 233.2 88 999999999 206.7 251.75 percent of total billed charges "INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)" 9510033_2 CDM 761 RC 51702 HCPCS outpatient 265 198.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 235.85 89 999999999 206.7 251.75 percent of total billed charges VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS) 9510040_1 CDM 722 RC 59409 HCPCS outpatient 8228 6171 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 7405.2 999999999 6417.84 7816.6 case rate VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS) 9510040_1 CDM 722 RC 59409 HCPCS outpatient 8228 6171 AETNA MCR ADV AETNA MCR ADV 6417.84 78 999999999 6417.84 7816.6 percent of total billed charges VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS) 9510040_1 CDM 722 RC 59409 HCPCS outpatient 8228 6171 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 7205.26 87.57 999999999 6417.84 7816.6 percent of total billed charges VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS) 9510040_1 CDM 722 RC 59409 HCPCS outpatient 8228 6171 COORDINATED CARE MCAID COORDINATED CARE MCAID 6999.56 85.07 999999999 6417.84 7816.6 percent of total billed charges VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS) 9510040_1 CDM 722 RC 59409 HCPCS outpatient 8228 6171 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 6999.56 85.07 999999999 6417.84 7816.6 percent of total billed charges VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS) 9510040_1 CDM 722 RC 59409 HCPCS outpatient 8228 6171 MOLINA MCAID MOLINA MCAID 6862.15 83.4 999999999 6417.84 7816.6 percent of total billed charges VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS) 9510040_1 CDM 722 RC 59409 HCPCS outpatient 8228 6171 MOLINA MCR ADV MOLINA MCR ADV 7322.92 89 999999999 6417.84 7816.6 percent of total billed charges VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS) 9510040_1 CDM 722 RC 59409 HCPCS outpatient 8228 6171 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 7322.92 89 999999999 6417.84 7816.6 percent of total billed charges VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS) 9510040_1 CDM 722 RC 59409 HCPCS outpatient 8228 6171 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 7322.92 89 999999999 6417.84 7816.6 percent of total billed charges VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS) 9510040_1 CDM 722 RC 59409 HCPCS outpatient 8228 6171 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 7405.2 90 999999999 6417.84 7816.6 percent of total billed charges VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS) 9510040_1 CDM 722 RC 59409 HCPCS outpatient 8228 6171 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 7816.6 95 999999999 6417.84 7816.6 percent of total billed charges VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS) 9510040_1 CDM 722 RC 59409 HCPCS outpatient 8228 6171 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 7816.6 95 999999999 6417.84 7816.6 percent of total billed charges VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS) 9510040_1 CDM 722 RC 59409 HCPCS outpatient 8228 6171 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 7322.92 89 999999999 6417.84 7816.6 percent of total billed charges VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS) 9510040_1 CDM 722 RC 59409 HCPCS outpatient 8228 6171 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 7240.64 88 999999999 6417.84 7816.6 percent of total billed charges VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS) 9510040_1 CDM 722 RC 59409 HCPCS outpatient 8228 6171 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 7322.92 89 999999999 6417.84 7816.6 percent of total billed charges "COLLECTION OF CAPILLARY BLOOD SPECIMEN (EG, FINGER, HEEL, EAR STICK)" 9510340_1 CDM 300 RC 36416 HCPCS outpatient 34 25.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 30.6 999999999 26.52 32.3 case rate "COLLECTION OF CAPILLARY BLOOD SPECIMEN (EG, FINGER, HEEL, EAR STICK)" 9510340_1 CDM 300 RC 36416 HCPCS outpatient 34 25.5 AETNA MCR ADV AETNA MCR ADV 26.52 78 999999999 26.52 32.3 percent of total billed charges "COLLECTION OF CAPILLARY BLOOD SPECIMEN (EG, FINGER, HEEL, EAR STICK)" 9510340_1 CDM 300 RC 36416 HCPCS outpatient 34 25.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 29.77 87.57 999999999 26.52 32.3 percent of total billed charges "COLLECTION OF CAPILLARY BLOOD SPECIMEN (EG, FINGER, HEEL, EAR STICK)" 9510340_1 CDM 300 RC 36416 HCPCS outpatient 34 25.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 28.92 85.07 999999999 26.52 32.3 percent of total billed charges "COLLECTION OF CAPILLARY BLOOD SPECIMEN (EG, FINGER, HEEL, EAR STICK)" 9510340_1 CDM 300 RC 36416 HCPCS outpatient 34 25.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 28.92 85.07 999999999 26.52 32.3 percent of total billed charges "COLLECTION OF CAPILLARY BLOOD SPECIMEN (EG, FINGER, HEEL, EAR STICK)" 9510340_1 CDM 300 RC 36416 HCPCS outpatient 34 25.5 MOLINA MCAID MOLINA MCAID 28.36 83.4 999999999 26.52 32.3 percent of total billed charges "COLLECTION OF CAPILLARY BLOOD SPECIMEN (EG, FINGER, HEEL, EAR STICK)" 9510340_1 CDM 300 RC 36416 HCPCS outpatient 34 25.5 MOLINA MCR ADV MOLINA MCR ADV 30.26 89 999999999 26.52 32.3 percent of total billed charges "COLLECTION OF CAPILLARY BLOOD SPECIMEN (EG, FINGER, HEEL, EAR STICK)" 9510340_1 CDM 300 RC 36416 HCPCS outpatient 34 25.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 30.26 89 999999999 26.52 32.3 percent of total billed charges "COLLECTION OF CAPILLARY BLOOD SPECIMEN (EG, FINGER, HEEL, EAR STICK)" 9510340_1 CDM 300 RC 36416 HCPCS outpatient 34 25.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 30.26 89 999999999 26.52 32.3 percent of total billed charges "COLLECTION OF CAPILLARY BLOOD SPECIMEN (EG, FINGER, HEEL, EAR STICK)" 9510340_1 CDM 300 RC 36416 HCPCS outpatient 34 25.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 30.6 90 999999999 26.52 32.3 percent of total billed charges "COLLECTION OF CAPILLARY BLOOD SPECIMEN (EG, FINGER, HEEL, EAR STICK)" 9510340_1 CDM 300 RC 36416 HCPCS outpatient 34 25.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 32.3 95 999999999 26.52 32.3 percent of total billed charges "COLLECTION OF CAPILLARY BLOOD SPECIMEN (EG, FINGER, HEEL, EAR STICK)" 9510340_1 CDM 300 RC 36416 HCPCS outpatient 34 25.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 32.3 95 999999999 26.52 32.3 percent of total billed charges "COLLECTION OF CAPILLARY BLOOD SPECIMEN (EG, FINGER, HEEL, EAR STICK)" 9510340_1 CDM 300 RC 36416 HCPCS outpatient 34 25.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 30.26 89 999999999 26.52 32.3 percent of total billed charges "COLLECTION OF CAPILLARY BLOOD SPECIMEN (EG, FINGER, HEEL, EAR STICK)" 9510340_1 CDM 300 RC 36416 HCPCS outpatient 34 25.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 29.92 88 999999999 26.52 32.3 percent of total billed charges "COLLECTION OF CAPILLARY BLOOD SPECIMEN (EG, FINGER, HEEL, EAR STICK)" 9510340_1 CDM 300 RC 36416 HCPCS outpatient 34 25.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 30.26 89 999999999 26.52 32.3 percent of total billed charges "PHLEBOTOMY, THERAPEUTIC (SEPARATE PROCEDURE)" 9510347_1 CDM 940 RC 99195 HCPCS outpatient 153 114.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 137.7 90 999999999 119.34 145.35 percent of total billed charges "PHLEBOTOMY, THERAPEUTIC (SEPARATE PROCEDURE)" 9510347_1 CDM 940 RC 99195 HCPCS outpatient 153 114.75 AETNA MCR ADV AETNA MCR ADV 119.34 78 999999999 119.34 145.35 percent of total billed charges "PHLEBOTOMY, THERAPEUTIC (SEPARATE PROCEDURE)" 9510347_1 CDM 940 RC 99195 HCPCS outpatient 153 114.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 133.98 87.57 999999999 119.34 145.35 percent of total billed charges "PHLEBOTOMY, THERAPEUTIC (SEPARATE PROCEDURE)" 9510347_1 CDM 940 RC 99195 HCPCS outpatient 153 114.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 130.16 85.07 999999999 119.34 145.35 percent of total billed charges "PHLEBOTOMY, THERAPEUTIC (SEPARATE PROCEDURE)" 9510347_1 CDM 940 RC 99195 HCPCS outpatient 153 114.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 130.16 85.07 999999999 119.34 145.35 percent of total billed charges "PHLEBOTOMY, THERAPEUTIC (SEPARATE PROCEDURE)" 9510347_1 CDM 940 RC 99195 HCPCS outpatient 153 114.75 MOLINA MCAID MOLINA MCAID 127.6 83.4 999999999 119.34 145.35 percent of total billed charges "PHLEBOTOMY, THERAPEUTIC (SEPARATE PROCEDURE)" 9510347_1 CDM 940 RC 99195 HCPCS outpatient 153 114.75 MOLINA MCR ADV MOLINA MCR ADV 136.17 89 999999999 119.34 145.35 percent of total billed charges "PHLEBOTOMY, THERAPEUTIC (SEPARATE PROCEDURE)" 9510347_1 CDM 940 RC 99195 HCPCS outpatient 153 114.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 136.17 89 999999999 119.34 145.35 percent of total billed charges "PHLEBOTOMY, THERAPEUTIC (SEPARATE PROCEDURE)" 9510347_1 CDM 940 RC 99195 HCPCS outpatient 153 114.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 136.17 89 999999999 119.34 145.35 percent of total billed charges "PHLEBOTOMY, THERAPEUTIC (SEPARATE PROCEDURE)" 9510347_1 CDM 940 RC 99195 HCPCS outpatient 153 114.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 137.7 90 999999999 119.34 145.35 percent of total billed charges "PHLEBOTOMY, THERAPEUTIC (SEPARATE PROCEDURE)" 9510347_1 CDM 940 RC 99195 HCPCS outpatient 153 114.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 145.35 95 999999999 119.34 145.35 percent of total billed charges "PHLEBOTOMY, THERAPEUTIC (SEPARATE PROCEDURE)" 9510347_1 CDM 940 RC 99195 HCPCS outpatient 153 114.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 145.35 95 999999999 119.34 145.35 percent of total billed charges "PHLEBOTOMY, THERAPEUTIC (SEPARATE PROCEDURE)" 9510347_1 CDM 940 RC 99195 HCPCS outpatient 153 114.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 136.17 89 999999999 119.34 145.35 percent of total billed charges "PHLEBOTOMY, THERAPEUTIC (SEPARATE PROCEDURE)" 9510347_1 CDM 940 RC 99195 HCPCS outpatient 153 114.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 134.64 88 999999999 119.34 145.35 percent of total billed charges "PHLEBOTOMY, THERAPEUTIC (SEPARATE PROCEDURE)" 9510347_1 CDM 940 RC 99195 HCPCS outpatient 153 114.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 136.17 89 999999999 119.34 145.35 percent of total billed charges "PHLEBOTOMY, THERAPEUTIC (SEPARATE PROCEDURE)" 9510347_2 CDM 940 RC 99195 HCPCS outpatient 153 114.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 137.7 90 999999999 119.34 145.35 percent of total billed charges "PHLEBOTOMY, THERAPEUTIC (SEPARATE PROCEDURE)" 9510347_2 CDM 940 RC 99195 HCPCS outpatient 153 114.75 AETNA MCR ADV AETNA MCR ADV 119.34 78 999999999 119.34 145.35 percent of total billed charges "PHLEBOTOMY, THERAPEUTIC (SEPARATE PROCEDURE)" 9510347_2 CDM 940 RC 99195 HCPCS outpatient 153 114.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 133.98 87.57 999999999 119.34 145.35 percent of total billed charges "PHLEBOTOMY, THERAPEUTIC (SEPARATE PROCEDURE)" 9510347_2 CDM 940 RC 99195 HCPCS outpatient 153 114.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 130.16 85.07 999999999 119.34 145.35 percent of total billed charges "PHLEBOTOMY, THERAPEUTIC (SEPARATE PROCEDURE)" 9510347_2 CDM 940 RC 99195 HCPCS outpatient 153 114.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 130.16 85.07 999999999 119.34 145.35 percent of total billed charges "PHLEBOTOMY, THERAPEUTIC (SEPARATE PROCEDURE)" 9510347_2 CDM 940 RC 99195 HCPCS outpatient 153 114.75 MOLINA MCAID MOLINA MCAID 127.6 83.4 999999999 119.34 145.35 percent of total billed charges "PHLEBOTOMY, THERAPEUTIC (SEPARATE PROCEDURE)" 9510347_2 CDM 940 RC 99195 HCPCS outpatient 153 114.75 MOLINA MCR ADV MOLINA MCR ADV 136.17 89 999999999 119.34 145.35 percent of total billed charges "PHLEBOTOMY, THERAPEUTIC (SEPARATE PROCEDURE)" 9510347_2 CDM 940 RC 99195 HCPCS outpatient 153 114.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 136.17 89 999999999 119.34 145.35 percent of total billed charges "PHLEBOTOMY, THERAPEUTIC (SEPARATE PROCEDURE)" 9510347_2 CDM 940 RC 99195 HCPCS outpatient 153 114.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 136.17 89 999999999 119.34 145.35 percent of total billed charges "PHLEBOTOMY, THERAPEUTIC (SEPARATE PROCEDURE)" 9510347_2 CDM 940 RC 99195 HCPCS outpatient 153 114.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 137.7 90 999999999 119.34 145.35 percent of total billed charges "PHLEBOTOMY, THERAPEUTIC (SEPARATE PROCEDURE)" 9510347_2 CDM 940 RC 99195 HCPCS outpatient 153 114.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 145.35 95 999999999 119.34 145.35 percent of total billed charges "PHLEBOTOMY, THERAPEUTIC (SEPARATE PROCEDURE)" 9510347_2 CDM 940 RC 99195 HCPCS outpatient 153 114.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 145.35 95 999999999 119.34 145.35 percent of total billed charges "PHLEBOTOMY, THERAPEUTIC (SEPARATE PROCEDURE)" 9510347_2 CDM 940 RC 99195 HCPCS outpatient 153 114.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 136.17 89 999999999 119.34 145.35 percent of total billed charges "PHLEBOTOMY, THERAPEUTIC (SEPARATE PROCEDURE)" 9510347_2 CDM 940 RC 99195 HCPCS outpatient 153 114.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 134.64 88 999999999 119.34 145.35 percent of total billed charges "PHLEBOTOMY, THERAPEUTIC (SEPARATE PROCEDURE)" 9510347_2 CDM 940 RC 99195 HCPCS outpatient 153 114.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 136.17 89 999999999 119.34 145.35 percent of total billed charges COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE 9510355_1 CDM 300 RC 36415 HCPCS outpatient 37 27.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 33.3 999999999 28.86 35.15 case rate COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE 9510355_1 CDM 300 RC 36415 HCPCS outpatient 37 27.75 AETNA MCR ADV AETNA MCR ADV 28.86 78 999999999 28.86 35.15 percent of total billed charges COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE 9510355_1 CDM 300 RC 36415 HCPCS outpatient 37 27.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 32.4 87.57 999999999 28.86 35.15 percent of total billed charges COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE 9510355_1 CDM 300 RC 36415 HCPCS outpatient 37 27.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 31.48 85.07 999999999 28.86 35.15 percent of total billed charges COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE 9510355_1 CDM 300 RC 36415 HCPCS outpatient 37 27.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 31.48 85.07 999999999 28.86 35.15 percent of total billed charges COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE 9510355_1 CDM 300 RC 36415 HCPCS outpatient 37 27.75 MOLINA MCAID MOLINA MCAID 30.86 83.4 999999999 28.86 35.15 percent of total billed charges COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE 9510355_1 CDM 300 RC 36415 HCPCS outpatient 37 27.75 MOLINA MCR ADV MOLINA MCR ADV 32.93 89 999999999 28.86 35.15 percent of total billed charges COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE 9510355_1 CDM 300 RC 36415 HCPCS outpatient 37 27.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 32.93 89 999999999 28.86 35.15 percent of total billed charges COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE 9510355_1 CDM 300 RC 36415 HCPCS outpatient 37 27.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 32.93 89 999999999 28.86 35.15 percent of total billed charges COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE 9510355_1 CDM 300 RC 36415 HCPCS outpatient 37 27.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 33.3 90 999999999 28.86 35.15 percent of total billed charges COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE 9510355_1 CDM 300 RC 36415 HCPCS outpatient 37 27.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 35.15 95 999999999 28.86 35.15 percent of total billed charges COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE 9510355_1 CDM 300 RC 36415 HCPCS outpatient 37 27.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 35.15 95 999999999 28.86 35.15 percent of total billed charges COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE 9510355_1 CDM 300 RC 36415 HCPCS outpatient 37 27.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 32.93 89 999999999 28.86 35.15 percent of total billed charges COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE 9510355_1 CDM 300 RC 36415 HCPCS outpatient 37 27.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 32.56 88 999999999 28.86 35.15 percent of total billed charges COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE 9510355_1 CDM 300 RC 36415 HCPCS outpatient 37 27.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 32.93 89 999999999 28.86 35.15 percent of total billed charges "CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE, PROUD FLESH)" 9510361_1 CDM 361 RC 17250 HCPCS outpatient 226 169.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 203.4 999999999 176.28 214.7 case rate "CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE, PROUD FLESH)" 9510361_1 CDM 361 RC 17250 HCPCS outpatient 226 169.5 AETNA MCR ADV AETNA MCR ADV 176.28 78 999999999 176.28 214.7 percent of total billed charges "CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE, PROUD FLESH)" 9510361_1 CDM 361 RC 17250 HCPCS outpatient 226 169.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 197.91 87.57 999999999 176.28 214.7 percent of total billed charges "CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE, PROUD FLESH)" 9510361_1 CDM 361 RC 17250 HCPCS outpatient 226 169.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 192.26 85.07 999999999 176.28 214.7 percent of total billed charges "CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE, PROUD FLESH)" 9510361_1 CDM 361 RC 17250 HCPCS outpatient 226 169.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 192.26 85.07 999999999 176.28 214.7 percent of total billed charges "CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE, PROUD FLESH)" 9510361_1 CDM 361 RC 17250 HCPCS outpatient 226 169.5 MOLINA MCAID MOLINA MCAID 188.48 83.4 999999999 176.28 214.7 percent of total billed charges "CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE, PROUD FLESH)" 9510361_1 CDM 361 RC 17250 HCPCS outpatient 226 169.5 MOLINA MCR ADV MOLINA MCR ADV 201.14 89 999999999 176.28 214.7 percent of total billed charges "CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE, PROUD FLESH)" 9510361_1 CDM 361 RC 17250 HCPCS outpatient 226 169.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 201.14 89 999999999 176.28 214.7 percent of total billed charges "CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE, PROUD FLESH)" 9510361_1 CDM 361 RC 17250 HCPCS outpatient 226 169.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 201.14 89 999999999 176.28 214.7 percent of total billed charges "CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE, PROUD FLESH)" 9510361_1 CDM 361 RC 17250 HCPCS outpatient 226 169.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 203.4 90 999999999 176.28 214.7 percent of total billed charges "CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE, PROUD FLESH)" 9510361_1 CDM 361 RC 17250 HCPCS outpatient 226 169.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 214.7 95 999999999 176.28 214.7 percent of total billed charges "CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE, PROUD FLESH)" 9510361_1 CDM 361 RC 17250 HCPCS outpatient 226 169.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 214.7 95 999999999 176.28 214.7 percent of total billed charges "CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE, PROUD FLESH)" 9510361_1 CDM 361 RC 17250 HCPCS outpatient 226 169.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 201.14 89 999999999 176.28 214.7 percent of total billed charges "CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE, PROUD FLESH)" 9510361_1 CDM 361 RC 17250 HCPCS outpatient 226 169.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 198.88 88 999999999 176.28 214.7 percent of total billed charges "CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE, PROUD FLESH)" 9510361_1 CDM 361 RC 17250 HCPCS outpatient 226 169.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 201.14 89 999999999 176.28 214.7 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510365_1 CDM 771 RC 90472 HCPCS outpatient 81 60.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 72.9 90 999999999 63.18 76.95 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510365_1 CDM 771 RC 90472 HCPCS outpatient 81 60.75 AETNA MCR ADV AETNA MCR ADV 63.18 78 999999999 63.18 76.95 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510365_1 CDM 771 RC 90472 HCPCS outpatient 81 60.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 70.93 87.57 999999999 63.18 76.95 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510365_1 CDM 771 RC 90472 HCPCS outpatient 81 60.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 68.91 85.07 999999999 63.18 76.95 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510365_1 CDM 771 RC 90472 HCPCS outpatient 81 60.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 68.91 85.07 999999999 63.18 76.95 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510365_1 CDM 771 RC 90472 HCPCS outpatient 81 60.75 MOLINA MCAID MOLINA MCAID 67.55 83.4 999999999 63.18 76.95 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510365_1 CDM 771 RC 90472 HCPCS outpatient 81 60.75 MOLINA MCR ADV MOLINA MCR ADV 72.09 89 999999999 63.18 76.95 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510365_1 CDM 771 RC 90472 HCPCS outpatient 81 60.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 72.09 89 999999999 63.18 76.95 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510365_1 CDM 771 RC 90472 HCPCS outpatient 81 60.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 72.09 89 999999999 63.18 76.95 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510365_1 CDM 771 RC 90472 HCPCS outpatient 81 60.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 72.9 90 999999999 63.18 76.95 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510365_1 CDM 771 RC 90472 HCPCS outpatient 81 60.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 76.95 95 999999999 63.18 76.95 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510365_1 CDM 771 RC 90472 HCPCS outpatient 81 60.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 76.95 95 999999999 63.18 76.95 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510365_1 CDM 771 RC 90472 HCPCS outpatient 81 60.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 72.09 89 999999999 63.18 76.95 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510365_1 CDM 771 RC 90472 HCPCS outpatient 81 60.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 71.28 88 999999999 63.18 76.95 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510365_1 CDM 771 RC 90472 HCPCS outpatient 81 60.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 72.09 89 999999999 63.18 76.95 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510365_2 CDM 771 RC 90472 HCPCS outpatient 81 60.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 72.9 90 999999999 63.18 76.95 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510365_2 CDM 771 RC 90472 HCPCS outpatient 81 60.75 AETNA MCR ADV AETNA MCR ADV 63.18 78 999999999 63.18 76.95 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510365_2 CDM 771 RC 90472 HCPCS outpatient 81 60.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 70.93 87.57 999999999 63.18 76.95 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510365_2 CDM 771 RC 90472 HCPCS outpatient 81 60.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 68.91 85.07 999999999 63.18 76.95 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510365_2 CDM 771 RC 90472 HCPCS outpatient 81 60.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 68.91 85.07 999999999 63.18 76.95 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510365_2 CDM 771 RC 90472 HCPCS outpatient 81 60.75 MOLINA MCAID MOLINA MCAID 67.55 83.4 999999999 63.18 76.95 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510365_2 CDM 771 RC 90472 HCPCS outpatient 81 60.75 MOLINA MCR ADV MOLINA MCR ADV 72.09 89 999999999 63.18 76.95 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510365_2 CDM 771 RC 90472 HCPCS outpatient 81 60.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 72.09 89 999999999 63.18 76.95 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510365_2 CDM 771 RC 90472 HCPCS outpatient 81 60.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 72.09 89 999999999 63.18 76.95 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510365_2 CDM 771 RC 90472 HCPCS outpatient 81 60.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 72.9 90 999999999 63.18 76.95 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510365_2 CDM 771 RC 90472 HCPCS outpatient 81 60.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 76.95 95 999999999 63.18 76.95 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510365_2 CDM 771 RC 90472 HCPCS outpatient 81 60.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 76.95 95 999999999 63.18 76.95 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510365_2 CDM 771 RC 90472 HCPCS outpatient 81 60.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 72.09 89 999999999 63.18 76.95 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510365_2 CDM 771 RC 90472 HCPCS outpatient 81 60.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 71.28 88 999999999 63.18 76.95 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510365_2 CDM 771 RC 90472 HCPCS outpatient 81 60.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 72.09 89 999999999 63.18 76.95 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 9510366_1 CDM 771 RC 90471 HCPCS outpatient 95 71.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 85.5 90 999999999 74.1 90.25 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 9510366_1 CDM 771 RC 90471 HCPCS outpatient 95 71.25 AETNA MCR ADV AETNA MCR ADV 74.1 78 999999999 74.1 90.25 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 9510366_1 CDM 771 RC 90471 HCPCS outpatient 95 71.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 83.19 87.57 999999999 74.1 90.25 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 9510366_1 CDM 771 RC 90471 HCPCS outpatient 95 71.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 80.82 85.07 999999999 74.1 90.25 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 9510366_1 CDM 771 RC 90471 HCPCS outpatient 95 71.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 80.82 85.07 999999999 74.1 90.25 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 9510366_1 CDM 771 RC 90471 HCPCS outpatient 95 71.25 MOLINA MCAID MOLINA MCAID 79.23 83.4 999999999 74.1 90.25 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 9510366_1 CDM 771 RC 90471 HCPCS outpatient 95 71.25 MOLINA MCR ADV MOLINA MCR ADV 84.55 89 999999999 74.1 90.25 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 9510366_1 CDM 771 RC 90471 HCPCS outpatient 95 71.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 84.55 89 999999999 74.1 90.25 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 9510366_1 CDM 771 RC 90471 HCPCS outpatient 95 71.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 84.55 89 999999999 74.1 90.25 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 9510366_1 CDM 771 RC 90471 HCPCS outpatient 95 71.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 85.5 90 999999999 74.1 90.25 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 9510366_1 CDM 771 RC 90471 HCPCS outpatient 95 71.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 90.25 95 999999999 74.1 90.25 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 9510366_1 CDM 771 RC 90471 HCPCS outpatient 95 71.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 90.25 95 999999999 74.1 90.25 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 9510366_1 CDM 771 RC 90471 HCPCS outpatient 95 71.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 84.55 89 999999999 74.1 90.25 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 9510366_1 CDM 771 RC 90471 HCPCS outpatient 95 71.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 83.6 88 999999999 74.1 90.25 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 9510366_1 CDM 771 RC 90471 HCPCS outpatient 95 71.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 84.55 89 999999999 74.1 90.25 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 9510366_2 CDM 771 RC 90471 HCPCS outpatient 95 71.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 85.5 90 999999999 74.1 90.25 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 9510366_2 CDM 771 RC 90471 HCPCS outpatient 95 71.25 AETNA MCR ADV AETNA MCR ADV 74.1 78 999999999 74.1 90.25 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 9510366_2 CDM 771 RC 90471 HCPCS outpatient 95 71.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 83.19 87.57 999999999 74.1 90.25 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 9510366_2 CDM 771 RC 90471 HCPCS outpatient 95 71.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 80.82 85.07 999999999 74.1 90.25 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 9510366_2 CDM 771 RC 90471 HCPCS outpatient 95 71.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 80.82 85.07 999999999 74.1 90.25 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 9510366_2 CDM 771 RC 90471 HCPCS outpatient 95 71.25 MOLINA MCAID MOLINA MCAID 79.23 83.4 999999999 74.1 90.25 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 9510366_2 CDM 771 RC 90471 HCPCS outpatient 95 71.25 MOLINA MCR ADV MOLINA MCR ADV 84.55 89 999999999 74.1 90.25 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 9510366_2 CDM 771 RC 90471 HCPCS outpatient 95 71.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 84.55 89 999999999 74.1 90.25 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 9510366_2 CDM 771 RC 90471 HCPCS outpatient 95 71.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 84.55 89 999999999 74.1 90.25 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 9510366_2 CDM 771 RC 90471 HCPCS outpatient 95 71.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 85.5 90 999999999 74.1 90.25 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 9510366_2 CDM 771 RC 90471 HCPCS outpatient 95 71.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 90.25 95 999999999 74.1 90.25 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 9510366_2 CDM 771 RC 90471 HCPCS outpatient 95 71.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 90.25 95 999999999 74.1 90.25 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 9510366_2 CDM 771 RC 90471 HCPCS outpatient 95 71.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 84.55 89 999999999 74.1 90.25 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 9510366_2 CDM 771 RC 90471 HCPCS outpatient 95 71.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 83.6 88 999999999 74.1 90.25 percent of total billed charges "IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID)" 9510366_2 CDM 771 RC 90471 HCPCS outpatient 95 71.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 84.55 89 999999999 74.1 90.25 percent of total billed charges "TRANSFUSION, BLOOD OR BLOOD COMPONENTS" 9510379_1 CDM 391 RC 36430 HCPCS outpatient 1865 1398.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1678.5 999999999 1454.7 1771.75 case rate "TRANSFUSION, BLOOD OR BLOOD COMPONENTS" 9510379_1 CDM 391 RC 36430 HCPCS outpatient 1865 1398.75 AETNA MCR ADV AETNA MCR ADV 1454.7 78 999999999 1454.7 1771.75 percent of total billed charges "TRANSFUSION, BLOOD OR BLOOD COMPONENTS" 9510379_1 CDM 391 RC 36430 HCPCS outpatient 1865 1398.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1633.18 87.57 999999999 1454.7 1771.75 percent of total billed charges "TRANSFUSION, BLOOD OR BLOOD COMPONENTS" 9510379_1 CDM 391 RC 36430 HCPCS outpatient 1865 1398.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 1586.56 85.07 999999999 1454.7 1771.75 percent of total billed charges "TRANSFUSION, BLOOD OR BLOOD COMPONENTS" 9510379_1 CDM 391 RC 36430 HCPCS outpatient 1865 1398.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1586.56 85.07 999999999 1454.7 1771.75 percent of total billed charges "TRANSFUSION, BLOOD OR BLOOD COMPONENTS" 9510379_1 CDM 391 RC 36430 HCPCS outpatient 1865 1398.75 MOLINA MCAID MOLINA MCAID 1555.41 83.4 999999999 1454.7 1771.75 percent of total billed charges "TRANSFUSION, BLOOD OR BLOOD COMPONENTS" 9510379_1 CDM 391 RC 36430 HCPCS outpatient 1865 1398.75 MOLINA MCR ADV MOLINA MCR ADV 1659.85 89 999999999 1454.7 1771.75 percent of total billed charges "TRANSFUSION, BLOOD OR BLOOD COMPONENTS" 9510379_1 CDM 391 RC 36430 HCPCS outpatient 1865 1398.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1659.85 89 999999999 1454.7 1771.75 percent of total billed charges "TRANSFUSION, BLOOD OR BLOOD COMPONENTS" 9510379_1 CDM 391 RC 36430 HCPCS outpatient 1865 1398.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1659.85 89 999999999 1454.7 1771.75 percent of total billed charges "TRANSFUSION, BLOOD OR BLOOD COMPONENTS" 9510379_1 CDM 391 RC 36430 HCPCS outpatient 1865 1398.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1678.5 90 999999999 1454.7 1771.75 percent of total billed charges "TRANSFUSION, BLOOD OR BLOOD COMPONENTS" 9510379_1 CDM 391 RC 36430 HCPCS outpatient 1865 1398.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1771.75 95 999999999 1454.7 1771.75 percent of total billed charges "TRANSFUSION, BLOOD OR BLOOD COMPONENTS" 9510379_1 CDM 391 RC 36430 HCPCS outpatient 1865 1398.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1771.75 95 999999999 1454.7 1771.75 percent of total billed charges "TRANSFUSION, BLOOD OR BLOOD COMPONENTS" 9510379_1 CDM 391 RC 36430 HCPCS outpatient 1865 1398.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1659.85 89 999999999 1454.7 1771.75 percent of total billed charges "TRANSFUSION, BLOOD OR BLOOD COMPONENTS" 9510379_1 CDM 391 RC 36430 HCPCS outpatient 1865 1398.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1641.2 88 999999999 1454.7 1771.75 percent of total billed charges "TRANSFUSION, BLOOD OR BLOOD COMPONENTS" 9510379_1 CDM 391 RC 36430 HCPCS outpatient 1865 1398.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1659.85 89 999999999 1454.7 1771.75 percent of total billed charges IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVERY SYSTEMS 9510396_1 CDM 761 RC 96523 HCPCS outpatient 170 127.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 153 90 999999999 132.6 161.5 percent of total billed charges IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVERY SYSTEMS 9510396_1 CDM 761 RC 96523 HCPCS outpatient 170 127.5 AETNA MCR ADV AETNA MCR ADV 132.6 78 999999999 132.6 161.5 percent of total billed charges IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVERY SYSTEMS 9510396_1 CDM 761 RC 96523 HCPCS outpatient 170 127.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 148.87 87.57 999999999 132.6 161.5 percent of total billed charges IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVERY SYSTEMS 9510396_1 CDM 761 RC 96523 HCPCS outpatient 170 127.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 144.62 85.07 999999999 132.6 161.5 percent of total billed charges IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVERY SYSTEMS 9510396_1 CDM 761 RC 96523 HCPCS outpatient 170 127.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 144.62 85.07 999999999 132.6 161.5 percent of total billed charges IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVERY SYSTEMS 9510396_1 CDM 761 RC 96523 HCPCS outpatient 170 127.5 MOLINA MCAID MOLINA MCAID 141.78 83.4 999999999 132.6 161.5 percent of total billed charges IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVERY SYSTEMS 9510396_1 CDM 761 RC 96523 HCPCS outpatient 170 127.5 MOLINA MCR ADV MOLINA MCR ADV 151.3 89 999999999 132.6 161.5 percent of total billed charges IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVERY SYSTEMS 9510396_1 CDM 761 RC 96523 HCPCS outpatient 170 127.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 151.3 89 999999999 132.6 161.5 percent of total billed charges IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVERY SYSTEMS 9510396_1 CDM 761 RC 96523 HCPCS outpatient 170 127.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 151.3 89 999999999 132.6 161.5 percent of total billed charges IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVERY SYSTEMS 9510396_1 CDM 761 RC 96523 HCPCS outpatient 170 127.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 153 90 999999999 132.6 161.5 percent of total billed charges IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVERY SYSTEMS 9510396_1 CDM 761 RC 96523 HCPCS outpatient 170 127.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 161.5 95 999999999 132.6 161.5 percent of total billed charges IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVERY SYSTEMS 9510396_1 CDM 761 RC 96523 HCPCS outpatient 170 127.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 161.5 95 999999999 132.6 161.5 percent of total billed charges IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVERY SYSTEMS 9510396_1 CDM 761 RC 96523 HCPCS outpatient 170 127.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 151.3 89 999999999 132.6 161.5 percent of total billed charges IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVERY SYSTEMS 9510396_1 CDM 761 RC 96523 HCPCS outpatient 170 127.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 149.6 88 999999999 132.6 161.5 percent of total billed charges IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVERY SYSTEMS 9510396_1 CDM 761 RC 96523 HCPCS outpatient 170 127.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 151.3 89 999999999 132.6 161.5 percent of total billed charges IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVERY SYSTEMS 9510396_2 CDM 761 RC 96523 HCPCS outpatient 170 127.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 153 90 999999999 132.6 161.5 percent of total billed charges IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVERY SYSTEMS 9510396_2 CDM 761 RC 96523 HCPCS outpatient 170 127.5 AETNA MCR ADV AETNA MCR ADV 132.6 78 999999999 132.6 161.5 percent of total billed charges IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVERY SYSTEMS 9510396_2 CDM 761 RC 96523 HCPCS outpatient 170 127.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 148.87 87.57 999999999 132.6 161.5 percent of total billed charges IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVERY SYSTEMS 9510396_2 CDM 761 RC 96523 HCPCS outpatient 170 127.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 144.62 85.07 999999999 132.6 161.5 percent of total billed charges IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVERY SYSTEMS 9510396_2 CDM 761 RC 96523 HCPCS outpatient 170 127.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 144.62 85.07 999999999 132.6 161.5 percent of total billed charges IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVERY SYSTEMS 9510396_2 CDM 761 RC 96523 HCPCS outpatient 170 127.5 MOLINA MCAID MOLINA MCAID 141.78 83.4 999999999 132.6 161.5 percent of total billed charges IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVERY SYSTEMS 9510396_2 CDM 761 RC 96523 HCPCS outpatient 170 127.5 MOLINA MCR ADV MOLINA MCR ADV 151.3 89 999999999 132.6 161.5 percent of total billed charges IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVERY SYSTEMS 9510396_2 CDM 761 RC 96523 HCPCS outpatient 170 127.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 151.3 89 999999999 132.6 161.5 percent of total billed charges IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVERY SYSTEMS 9510396_2 CDM 761 RC 96523 HCPCS outpatient 170 127.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 151.3 89 999999999 132.6 161.5 percent of total billed charges IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVERY SYSTEMS 9510396_2 CDM 761 RC 96523 HCPCS outpatient 170 127.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 153 90 999999999 132.6 161.5 percent of total billed charges IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVERY SYSTEMS 9510396_2 CDM 761 RC 96523 HCPCS outpatient 170 127.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 161.5 95 999999999 132.6 161.5 percent of total billed charges IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVERY SYSTEMS 9510396_2 CDM 761 RC 96523 HCPCS outpatient 170 127.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 161.5 95 999999999 132.6 161.5 percent of total billed charges IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVERY SYSTEMS 9510396_2 CDM 761 RC 96523 HCPCS outpatient 170 127.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 151.3 89 999999999 132.6 161.5 percent of total billed charges IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVERY SYSTEMS 9510396_2 CDM 761 RC 96523 HCPCS outpatient 170 127.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 149.6 88 999999999 132.6 161.5 percent of total billed charges IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG DELIVERY SYSTEMS 9510396_2 CDM 761 RC 96523 HCPCS outpatient 170 127.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 151.3 89 999999999 132.6 161.5 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); SUBCUTANEOUS OR INTRAMUSCULAR" 9510403_1 CDM 940 RC 96372 HCPCS outpatient 112 84 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 100.8 90 999999999 87.36 106.4 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); SUBCUTANEOUS OR INTRAMUSCULAR" 9510403_1 CDM 940 RC 96372 HCPCS outpatient 112 84 AETNA MCR ADV AETNA MCR ADV 87.36 78 999999999 87.36 106.4 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); SUBCUTANEOUS OR INTRAMUSCULAR" 9510403_1 CDM 940 RC 96372 HCPCS outpatient 112 84 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 98.08 87.57 999999999 87.36 106.4 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); SUBCUTANEOUS OR INTRAMUSCULAR" 9510403_1 CDM 940 RC 96372 HCPCS outpatient 112 84 COORDINATED CARE MCAID COORDINATED CARE MCAID 95.28 85.07 999999999 87.36 106.4 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); SUBCUTANEOUS OR INTRAMUSCULAR" 9510403_1 CDM 940 RC 96372 HCPCS outpatient 112 84 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 95.28 85.07 999999999 87.36 106.4 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); SUBCUTANEOUS OR INTRAMUSCULAR" 9510403_1 CDM 940 RC 96372 HCPCS outpatient 112 84 MOLINA MCAID MOLINA MCAID 93.41 83.4 999999999 87.36 106.4 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); SUBCUTANEOUS OR INTRAMUSCULAR" 9510403_1 CDM 940 RC 96372 HCPCS outpatient 112 84 MOLINA MCR ADV MOLINA MCR ADV 99.68 89 999999999 87.36 106.4 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); SUBCUTANEOUS OR INTRAMUSCULAR" 9510403_1 CDM 940 RC 96372 HCPCS outpatient 112 84 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 99.68 89 999999999 87.36 106.4 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); SUBCUTANEOUS OR INTRAMUSCULAR" 9510403_1 CDM 940 RC 96372 HCPCS outpatient 112 84 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 99.68 89 999999999 87.36 106.4 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); SUBCUTANEOUS OR INTRAMUSCULAR" 9510403_1 CDM 940 RC 96372 HCPCS outpatient 112 84 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 100.8 90 999999999 87.36 106.4 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); SUBCUTANEOUS OR INTRAMUSCULAR" 9510403_1 CDM 940 RC 96372 HCPCS outpatient 112 84 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 106.4 95 999999999 87.36 106.4 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); SUBCUTANEOUS OR INTRAMUSCULAR" 9510403_1 CDM 940 RC 96372 HCPCS outpatient 112 84 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 106.4 95 999999999 87.36 106.4 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); SUBCUTANEOUS OR INTRAMUSCULAR" 9510403_1 CDM 940 RC 96372 HCPCS outpatient 112 84 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 99.68 89 999999999 87.36 106.4 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); SUBCUTANEOUS OR INTRAMUSCULAR" 9510403_1 CDM 940 RC 96372 HCPCS outpatient 112 84 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 98.56 88 999999999 87.36 106.4 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); SUBCUTANEOUS OR INTRAMUSCULAR" 9510403_1 CDM 940 RC 96372 HCPCS outpatient 112 84 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 99.68 89 999999999 87.36 106.4 percent of total billed charges "EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CONTINUOUS RHYTHM RECORDING AND STORAGE; RECORDING (INCLUDES CONNECTION, RECORDING, AND DISCONNECTION)" 9510434_1 CDM 731 RC 93225 HCPCS outpatient 320 240 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 288 90 999999999 249.6 304 percent of total billed charges "EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CONTINUOUS RHYTHM RECORDING AND STORAGE; RECORDING (INCLUDES CONNECTION, RECORDING, AND DISCONNECTION)" 9510434_1 CDM 731 RC 93225 HCPCS outpatient 320 240 AETNA MCR ADV AETNA MCR ADV 249.6 78 999999999 249.6 304 percent of total billed charges "EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CONTINUOUS RHYTHM RECORDING AND STORAGE; RECORDING (INCLUDES CONNECTION, RECORDING, AND DISCONNECTION)" 9510434_1 CDM 731 RC 93225 HCPCS outpatient 320 240 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 280.22 87.57 999999999 249.6 304 percent of total billed charges "EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CONTINUOUS RHYTHM RECORDING AND STORAGE; RECORDING (INCLUDES CONNECTION, RECORDING, AND DISCONNECTION)" 9510434_1 CDM 731 RC 93225 HCPCS outpatient 320 240 COORDINATED CARE MCAID COORDINATED CARE MCAID 272.22 85.07 999999999 249.6 304 percent of total billed charges "EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CONTINUOUS RHYTHM RECORDING AND STORAGE; RECORDING (INCLUDES CONNECTION, RECORDING, AND DISCONNECTION)" 9510434_1 CDM 731 RC 93225 HCPCS outpatient 320 240 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 272.22 85.07 999999999 249.6 304 percent of total billed charges "EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CONTINUOUS RHYTHM RECORDING AND STORAGE; RECORDING (INCLUDES CONNECTION, RECORDING, AND DISCONNECTION)" 9510434_1 CDM 731 RC 93225 HCPCS outpatient 320 240 MOLINA MCAID MOLINA MCAID 266.88 83.4 999999999 249.6 304 percent of total billed charges "EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CONTINUOUS RHYTHM RECORDING AND STORAGE; RECORDING (INCLUDES CONNECTION, RECORDING, AND DISCONNECTION)" 9510434_1 CDM 731 RC 93225 HCPCS outpatient 320 240 MOLINA MCR ADV MOLINA MCR ADV 284.8 89 999999999 249.6 304 percent of total billed charges "EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CONTINUOUS RHYTHM RECORDING AND STORAGE; RECORDING (INCLUDES CONNECTION, RECORDING, AND DISCONNECTION)" 9510434_1 CDM 731 RC 93225 HCPCS outpatient 320 240 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 284.8 89 999999999 249.6 304 percent of total billed charges "EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CONTINUOUS RHYTHM RECORDING AND STORAGE; RECORDING (INCLUDES CONNECTION, RECORDING, AND DISCONNECTION)" 9510434_1 CDM 731 RC 93225 HCPCS outpatient 320 240 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 284.8 89 999999999 249.6 304 percent of total billed charges "EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CONTINUOUS RHYTHM RECORDING AND STORAGE; RECORDING (INCLUDES CONNECTION, RECORDING, AND DISCONNECTION)" 9510434_1 CDM 731 RC 93225 HCPCS outpatient 320 240 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 288 90 999999999 249.6 304 percent of total billed charges "EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CONTINUOUS RHYTHM RECORDING AND STORAGE; RECORDING (INCLUDES CONNECTION, RECORDING, AND DISCONNECTION)" 9510434_1 CDM 731 RC 93225 HCPCS outpatient 320 240 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 304 95 999999999 249.6 304 percent of total billed charges "EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CONTINUOUS RHYTHM RECORDING AND STORAGE; RECORDING (INCLUDES CONNECTION, RECORDING, AND DISCONNECTION)" 9510434_1 CDM 731 RC 93225 HCPCS outpatient 320 240 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 304 95 999999999 249.6 304 percent of total billed charges "EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CONTINUOUS RHYTHM RECORDING AND STORAGE; RECORDING (INCLUDES CONNECTION, RECORDING, AND DISCONNECTION)" 9510434_1 CDM 731 RC 93225 HCPCS outpatient 320 240 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 284.8 89 999999999 249.6 304 percent of total billed charges "EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CONTINUOUS RHYTHM RECORDING AND STORAGE; RECORDING (INCLUDES CONNECTION, RECORDING, AND DISCONNECTION)" 9510434_1 CDM 731 RC 93225 HCPCS outpatient 320 240 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 281.6 88 999999999 249.6 304 percent of total billed charges "EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CONTINUOUS RHYTHM RECORDING AND STORAGE; RECORDING (INCLUDES CONNECTION, RECORDING, AND DISCONNECTION)" 9510434_1 CDM 731 RC 93225 HCPCS outpatient 320 240 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 284.8 89 999999999 249.6 304 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510486_1 CDM 490 RC 64421 HCPCS outpatient 740 555 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 666 999999999 577.2 703 case rate "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510486_1 CDM 490 RC 64421 HCPCS outpatient 740 555 AETNA MCR ADV AETNA MCR ADV 577.2 78 999999999 577.2 703 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510486_1 CDM 490 RC 64421 HCPCS outpatient 740 555 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 648.02 87.57 999999999 577.2 703 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510486_1 CDM 490 RC 64421 HCPCS outpatient 740 555 COORDINATED CARE MCAID COORDINATED CARE MCAID 629.52 85.07 999999999 577.2 703 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510486_1 CDM 490 RC 64421 HCPCS outpatient 740 555 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 629.52 85.07 999999999 577.2 703 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510486_1 CDM 490 RC 64421 HCPCS outpatient 740 555 MOLINA MCAID MOLINA MCAID 617.16 83.4 999999999 577.2 703 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510486_1 CDM 490 RC 64421 HCPCS outpatient 740 555 MOLINA MCR ADV MOLINA MCR ADV 658.6 89 999999999 577.2 703 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510486_1 CDM 490 RC 64421 HCPCS outpatient 740 555 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 658.6 89 999999999 577.2 703 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510486_1 CDM 490 RC 64421 HCPCS outpatient 740 555 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 658.6 89 999999999 577.2 703 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510486_1 CDM 490 RC 64421 HCPCS outpatient 740 555 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 666 90 999999999 577.2 703 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510486_1 CDM 490 RC 64421 HCPCS outpatient 740 555 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 703 95 999999999 577.2 703 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510486_1 CDM 490 RC 64421 HCPCS outpatient 740 555 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 703 95 999999999 577.2 703 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510486_1 CDM 490 RC 64421 HCPCS outpatient 740 555 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 658.6 89 999999999 577.2 703 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510486_1 CDM 490 RC 64421 HCPCS outpatient 740 555 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 651.2 88 999999999 577.2 703 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510486_1 CDM 490 RC 64421 HCPCS outpatient 740 555 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 658.6 89 999999999 577.2 703 percent of total billed charges "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 9510519_1 CDM 761 RC 51798 HCPCS outpatient 202 151.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 181.8 999999999 157.56 191.9 case rate "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 9510519_1 CDM 761 RC 51798 HCPCS outpatient 202 151.5 AETNA MCR ADV AETNA MCR ADV 157.56 78 999999999 157.56 191.9 percent of total billed charges "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 9510519_1 CDM 761 RC 51798 HCPCS outpatient 202 151.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 176.89 87.57 999999999 157.56 191.9 percent of total billed charges "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 9510519_1 CDM 761 RC 51798 HCPCS outpatient 202 151.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 171.84 85.07 999999999 157.56 191.9 percent of total billed charges "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 9510519_1 CDM 761 RC 51798 HCPCS outpatient 202 151.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 171.84 85.07 999999999 157.56 191.9 percent of total billed charges "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 9510519_1 CDM 761 RC 51798 HCPCS outpatient 202 151.5 MOLINA MCAID MOLINA MCAID 168.47 83.4 999999999 157.56 191.9 percent of total billed charges "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 9510519_1 CDM 761 RC 51798 HCPCS outpatient 202 151.5 MOLINA MCR ADV MOLINA MCR ADV 179.78 89 999999999 157.56 191.9 percent of total billed charges "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 9510519_1 CDM 761 RC 51798 HCPCS outpatient 202 151.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 179.78 89 999999999 157.56 191.9 percent of total billed charges "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 9510519_1 CDM 761 RC 51798 HCPCS outpatient 202 151.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 179.78 89 999999999 157.56 191.9 percent of total billed charges "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 9510519_1 CDM 761 RC 51798 HCPCS outpatient 202 151.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 181.8 90 999999999 157.56 191.9 percent of total billed charges "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 9510519_1 CDM 761 RC 51798 HCPCS outpatient 202 151.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 191.9 95 999999999 157.56 191.9 percent of total billed charges "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 9510519_1 CDM 761 RC 51798 HCPCS outpatient 202 151.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 191.9 95 999999999 157.56 191.9 percent of total billed charges "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 9510519_1 CDM 761 RC 51798 HCPCS outpatient 202 151.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 179.78 89 999999999 157.56 191.9 percent of total billed charges "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 9510519_1 CDM 761 RC 51798 HCPCS outpatient 202 151.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 177.76 88 999999999 157.56 191.9 percent of total billed charges "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 9510519_1 CDM 761 RC 51798 HCPCS outpatient 202 151.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 179.78 89 999999999 157.56 191.9 percent of total billed charges "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 9510519_2 CDM 761 RC 51798 HCPCS outpatient 202 151.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 181.8 999999999 157.56 191.9 case rate "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 9510519_2 CDM 761 RC 51798 HCPCS outpatient 202 151.5 AETNA MCR ADV AETNA MCR ADV 157.56 78 999999999 157.56 191.9 percent of total billed charges "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 9510519_2 CDM 761 RC 51798 HCPCS outpatient 202 151.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 176.89 87.57 999999999 157.56 191.9 percent of total billed charges "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 9510519_2 CDM 761 RC 51798 HCPCS outpatient 202 151.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 171.84 85.07 999999999 157.56 191.9 percent of total billed charges "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 9510519_2 CDM 761 RC 51798 HCPCS outpatient 202 151.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 171.84 85.07 999999999 157.56 191.9 percent of total billed charges "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 9510519_2 CDM 761 RC 51798 HCPCS outpatient 202 151.5 MOLINA MCAID MOLINA MCAID 168.47 83.4 999999999 157.56 191.9 percent of total billed charges "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 9510519_2 CDM 761 RC 51798 HCPCS outpatient 202 151.5 MOLINA MCR ADV MOLINA MCR ADV 179.78 89 999999999 157.56 191.9 percent of total billed charges "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 9510519_2 CDM 761 RC 51798 HCPCS outpatient 202 151.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 179.78 89 999999999 157.56 191.9 percent of total billed charges "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 9510519_2 CDM 761 RC 51798 HCPCS outpatient 202 151.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 179.78 89 999999999 157.56 191.9 percent of total billed charges "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 9510519_2 CDM 761 RC 51798 HCPCS outpatient 202 151.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 181.8 90 999999999 157.56 191.9 percent of total billed charges "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 9510519_2 CDM 761 RC 51798 HCPCS outpatient 202 151.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 191.9 95 999999999 157.56 191.9 percent of total billed charges "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 9510519_2 CDM 761 RC 51798 HCPCS outpatient 202 151.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 191.9 95 999999999 157.56 191.9 percent of total billed charges "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 9510519_2 CDM 761 RC 51798 HCPCS outpatient 202 151.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 179.78 89 999999999 157.56 191.9 percent of total billed charges "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 9510519_2 CDM 761 RC 51798 HCPCS outpatient 202 151.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 177.76 88 999999999 157.56 191.9 percent of total billed charges "MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING" 9510519_2 CDM 761 RC 51798 HCPCS outpatient 202 151.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 179.78 89 999999999 157.56 191.9 percent of total billed charges "WHEELCHAIR MANAGEMENT (EG, ASSESSMENT, FITTING, TRAINING), EACH 15 MINUTES" 9510593_1 CDM 430 RC 97542 HCPCS outpatient 93 69.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 83.7 90 999999999 72.54 88.35 percent of total billed charges "WHEELCHAIR MANAGEMENT (EG, ASSESSMENT, FITTING, TRAINING), EACH 15 MINUTES" 9510593_1 CDM 430 RC 97542 HCPCS outpatient 93 69.75 AETNA MCR ADV AETNA MCR ADV 72.54 78 999999999 72.54 88.35 percent of total billed charges "WHEELCHAIR MANAGEMENT (EG, ASSESSMENT, FITTING, TRAINING), EACH 15 MINUTES" 9510593_1 CDM 430 RC 97542 HCPCS outpatient 93 69.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 81.44 87.57 999999999 72.54 88.35 percent of total billed charges "WHEELCHAIR MANAGEMENT (EG, ASSESSMENT, FITTING, TRAINING), EACH 15 MINUTES" 9510593_1 CDM 430 RC 97542 HCPCS outpatient 93 69.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 79.12 85.07 999999999 72.54 88.35 percent of total billed charges "WHEELCHAIR MANAGEMENT (EG, ASSESSMENT, FITTING, TRAINING), EACH 15 MINUTES" 9510593_1 CDM 430 RC 97542 HCPCS outpatient 93 69.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 79.12 85.07 999999999 72.54 88.35 percent of total billed charges "WHEELCHAIR MANAGEMENT (EG, ASSESSMENT, FITTING, TRAINING), EACH 15 MINUTES" 9510593_1 CDM 430 RC 97542 HCPCS outpatient 93 69.75 MOLINA MCAID MOLINA MCAID 77.56 83.4 999999999 72.54 88.35 percent of total billed charges "WHEELCHAIR MANAGEMENT (EG, ASSESSMENT, FITTING, TRAINING), EACH 15 MINUTES" 9510593_1 CDM 430 RC 97542 HCPCS outpatient 93 69.75 MOLINA MCR ADV MOLINA MCR ADV 82.77 89 999999999 72.54 88.35 percent of total billed charges "WHEELCHAIR MANAGEMENT (EG, ASSESSMENT, FITTING, TRAINING), EACH 15 MINUTES" 9510593_1 CDM 430 RC 97542 HCPCS outpatient 93 69.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 82.77 89 999999999 72.54 88.35 percent of total billed charges "WHEELCHAIR MANAGEMENT (EG, ASSESSMENT, FITTING, TRAINING), EACH 15 MINUTES" 9510593_1 CDM 430 RC 97542 HCPCS outpatient 93 69.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 82.77 89 999999999 72.54 88.35 percent of total billed charges "WHEELCHAIR MANAGEMENT (EG, ASSESSMENT, FITTING, TRAINING), EACH 15 MINUTES" 9510593_1 CDM 430 RC 97542 HCPCS outpatient 93 69.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 83.7 90 999999999 72.54 88.35 percent of total billed charges "WHEELCHAIR MANAGEMENT (EG, ASSESSMENT, FITTING, TRAINING), EACH 15 MINUTES" 9510593_1 CDM 430 RC 97542 HCPCS outpatient 93 69.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 88.35 95 999999999 72.54 88.35 percent of total billed charges "WHEELCHAIR MANAGEMENT (EG, ASSESSMENT, FITTING, TRAINING), EACH 15 MINUTES" 9510593_1 CDM 430 RC 97542 HCPCS outpatient 93 69.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 88.35 95 999999999 72.54 88.35 percent of total billed charges "WHEELCHAIR MANAGEMENT (EG, ASSESSMENT, FITTING, TRAINING), EACH 15 MINUTES" 9510593_1 CDM 430 RC 97542 HCPCS outpatient 93 69.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 82.77 89 999999999 72.54 88.35 percent of total billed charges "WHEELCHAIR MANAGEMENT (EG, ASSESSMENT, FITTING, TRAINING), EACH 15 MINUTES" 9510593_1 CDM 430 RC 97542 HCPCS outpatient 93 69.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 81.84 88 999999999 72.54 88.35 percent of total billed charges "WHEELCHAIR MANAGEMENT (EG, ASSESSMENT, FITTING, TRAINING), EACH 15 MINUTES" 9510593_1 CDM 430 RC 97542 HCPCS outpatient 93 69.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 82.77 89 999999999 72.54 88.35 percent of total billed charges "EVALUATION FOR PRESCRIPTION FOR SPEECH-GENERATING AUGMENTATIVE AND ALTERNATIVE COMMUNICATION DEVICE, FACE-TO-FACE WITH THE PATIENT; FIRST HOUR" 9510604_1 CDM 444 RC 92607 HCPCS outpatient 502 376.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 451.8 90 999999999 391.56 476.9 percent of total billed charges "EVALUATION FOR PRESCRIPTION FOR SPEECH-GENERATING AUGMENTATIVE AND ALTERNATIVE COMMUNICATION DEVICE, FACE-TO-FACE WITH THE PATIENT; FIRST HOUR" 9510604_1 CDM 444 RC 92607 HCPCS outpatient 502 376.5 AETNA MCR ADV AETNA MCR ADV 391.56 78 999999999 391.56 476.9 percent of total billed charges "EVALUATION FOR PRESCRIPTION FOR SPEECH-GENERATING AUGMENTATIVE AND ALTERNATIVE COMMUNICATION DEVICE, FACE-TO-FACE WITH THE PATIENT; FIRST HOUR" 9510604_1 CDM 444 RC 92607 HCPCS outpatient 502 376.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 439.6 87.57 999999999 391.56 476.9 percent of total billed charges "EVALUATION FOR PRESCRIPTION FOR SPEECH-GENERATING AUGMENTATIVE AND ALTERNATIVE COMMUNICATION DEVICE, FACE-TO-FACE WITH THE PATIENT; FIRST HOUR" 9510604_1 CDM 444 RC 92607 HCPCS outpatient 502 376.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 427.05 85.07 999999999 391.56 476.9 percent of total billed charges "EVALUATION FOR PRESCRIPTION FOR SPEECH-GENERATING AUGMENTATIVE AND ALTERNATIVE COMMUNICATION DEVICE, FACE-TO-FACE WITH THE PATIENT; FIRST HOUR" 9510604_1 CDM 444 RC 92607 HCPCS outpatient 502 376.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 427.05 85.07 999999999 391.56 476.9 percent of total billed charges "EVALUATION FOR PRESCRIPTION FOR SPEECH-GENERATING AUGMENTATIVE AND ALTERNATIVE COMMUNICATION DEVICE, FACE-TO-FACE WITH THE PATIENT; FIRST HOUR" 9510604_1 CDM 444 RC 92607 HCPCS outpatient 502 376.5 MOLINA MCAID MOLINA MCAID 418.67 83.4 999999999 391.56 476.9 percent of total billed charges "EVALUATION FOR PRESCRIPTION FOR SPEECH-GENERATING AUGMENTATIVE AND ALTERNATIVE COMMUNICATION DEVICE, FACE-TO-FACE WITH THE PATIENT; FIRST HOUR" 9510604_1 CDM 444 RC 92607 HCPCS outpatient 502 376.5 MOLINA MCR ADV MOLINA MCR ADV 446.78 89 999999999 391.56 476.9 percent of total billed charges "EVALUATION FOR PRESCRIPTION FOR SPEECH-GENERATING AUGMENTATIVE AND ALTERNATIVE COMMUNICATION DEVICE, FACE-TO-FACE WITH THE PATIENT; FIRST HOUR" 9510604_1 CDM 444 RC 92607 HCPCS outpatient 502 376.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 446.78 89 999999999 391.56 476.9 percent of total billed charges "EVALUATION FOR PRESCRIPTION FOR SPEECH-GENERATING AUGMENTATIVE AND ALTERNATIVE COMMUNICATION DEVICE, FACE-TO-FACE WITH THE PATIENT; FIRST HOUR" 9510604_1 CDM 444 RC 92607 HCPCS outpatient 502 376.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 446.78 89 999999999 391.56 476.9 percent of total billed charges "EVALUATION FOR PRESCRIPTION FOR SPEECH-GENERATING AUGMENTATIVE AND ALTERNATIVE COMMUNICATION DEVICE, FACE-TO-FACE WITH THE PATIENT; FIRST HOUR" 9510604_1 CDM 444 RC 92607 HCPCS outpatient 502 376.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 451.8 90 999999999 391.56 476.9 percent of total billed charges "EVALUATION FOR PRESCRIPTION FOR SPEECH-GENERATING AUGMENTATIVE AND ALTERNATIVE COMMUNICATION DEVICE, FACE-TO-FACE WITH THE PATIENT; FIRST HOUR" 9510604_1 CDM 444 RC 92607 HCPCS outpatient 502 376.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 476.9 95 999999999 391.56 476.9 percent of total billed charges "EVALUATION FOR PRESCRIPTION FOR SPEECH-GENERATING AUGMENTATIVE AND ALTERNATIVE COMMUNICATION DEVICE, FACE-TO-FACE WITH THE PATIENT; FIRST HOUR" 9510604_1 CDM 444 RC 92607 HCPCS outpatient 502 376.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 476.9 95 999999999 391.56 476.9 percent of total billed charges "EVALUATION FOR PRESCRIPTION FOR SPEECH-GENERATING AUGMENTATIVE AND ALTERNATIVE COMMUNICATION DEVICE, FACE-TO-FACE WITH THE PATIENT; FIRST HOUR" 9510604_1 CDM 444 RC 92607 HCPCS outpatient 502 376.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 446.78 89 999999999 391.56 476.9 percent of total billed charges "EVALUATION FOR PRESCRIPTION FOR SPEECH-GENERATING AUGMENTATIVE AND ALTERNATIVE COMMUNICATION DEVICE, FACE-TO-FACE WITH THE PATIENT; FIRST HOUR" 9510604_1 CDM 444 RC 92607 HCPCS outpatient 502 376.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 441.76 88 999999999 391.56 476.9 percent of total billed charges "EVALUATION FOR PRESCRIPTION FOR SPEECH-GENERATING AUGMENTATIVE AND ALTERNATIVE COMMUNICATION DEVICE, FACE-TO-FACE WITH THE PATIENT; FIRST HOUR" 9510604_1 CDM 444 RC 92607 HCPCS outpatient 502 376.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 446.78 89 999999999 391.56 476.9 percent of total billed charges "EVALUATION FOR PRESCRIPTION FOR SPEECH-GENERATING AUGMENTATIVE AND ALTERNATIVE COMMUNICATION DEVICE, FACE-TO-FACE WITH THE PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510605_1 CDM 444 RC 92608 HCPCS outpatient 236 177 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 212.4 90 999999999 184.08 224.2 percent of total billed charges "EVALUATION FOR PRESCRIPTION FOR SPEECH-GENERATING AUGMENTATIVE AND ALTERNATIVE COMMUNICATION DEVICE, FACE-TO-FACE WITH THE PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510605_1 CDM 444 RC 92608 HCPCS outpatient 236 177 AETNA MCR ADV AETNA MCR ADV 184.08 78 999999999 184.08 224.2 percent of total billed charges "EVALUATION FOR PRESCRIPTION FOR SPEECH-GENERATING AUGMENTATIVE AND ALTERNATIVE COMMUNICATION DEVICE, FACE-TO-FACE WITH THE PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510605_1 CDM 444 RC 92608 HCPCS outpatient 236 177 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 206.67 87.57 999999999 184.08 224.2 percent of total billed charges "EVALUATION FOR PRESCRIPTION FOR SPEECH-GENERATING AUGMENTATIVE AND ALTERNATIVE COMMUNICATION DEVICE, FACE-TO-FACE WITH THE PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510605_1 CDM 444 RC 92608 HCPCS outpatient 236 177 COORDINATED CARE MCAID COORDINATED CARE MCAID 200.77 85.07 999999999 184.08 224.2 percent of total billed charges "EVALUATION FOR PRESCRIPTION FOR SPEECH-GENERATING AUGMENTATIVE AND ALTERNATIVE COMMUNICATION DEVICE, FACE-TO-FACE WITH THE PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510605_1 CDM 444 RC 92608 HCPCS outpatient 236 177 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 200.77 85.07 999999999 184.08 224.2 percent of total billed charges "EVALUATION FOR PRESCRIPTION FOR SPEECH-GENERATING AUGMENTATIVE AND ALTERNATIVE COMMUNICATION DEVICE, FACE-TO-FACE WITH THE PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510605_1 CDM 444 RC 92608 HCPCS outpatient 236 177 MOLINA MCAID MOLINA MCAID 196.82 83.4 999999999 184.08 224.2 percent of total billed charges "EVALUATION FOR PRESCRIPTION FOR SPEECH-GENERATING AUGMENTATIVE AND ALTERNATIVE COMMUNICATION DEVICE, FACE-TO-FACE WITH THE PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510605_1 CDM 444 RC 92608 HCPCS outpatient 236 177 MOLINA MCR ADV MOLINA MCR ADV 210.04 89 999999999 184.08 224.2 percent of total billed charges "EVALUATION FOR PRESCRIPTION FOR SPEECH-GENERATING AUGMENTATIVE AND ALTERNATIVE COMMUNICATION DEVICE, FACE-TO-FACE WITH THE PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510605_1 CDM 444 RC 92608 HCPCS outpatient 236 177 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 210.04 89 999999999 184.08 224.2 percent of total billed charges "EVALUATION FOR PRESCRIPTION FOR SPEECH-GENERATING AUGMENTATIVE AND ALTERNATIVE COMMUNICATION DEVICE, FACE-TO-FACE WITH THE PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510605_1 CDM 444 RC 92608 HCPCS outpatient 236 177 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 210.04 89 999999999 184.08 224.2 percent of total billed charges "EVALUATION FOR PRESCRIPTION FOR SPEECH-GENERATING AUGMENTATIVE AND ALTERNATIVE COMMUNICATION DEVICE, FACE-TO-FACE WITH THE PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510605_1 CDM 444 RC 92608 HCPCS outpatient 236 177 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 212.4 90 999999999 184.08 224.2 percent of total billed charges "EVALUATION FOR PRESCRIPTION FOR SPEECH-GENERATING AUGMENTATIVE AND ALTERNATIVE COMMUNICATION DEVICE, FACE-TO-FACE WITH THE PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510605_1 CDM 444 RC 92608 HCPCS outpatient 236 177 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 224.2 95 999999999 184.08 224.2 percent of total billed charges "EVALUATION FOR PRESCRIPTION FOR SPEECH-GENERATING AUGMENTATIVE AND ALTERNATIVE COMMUNICATION DEVICE, FACE-TO-FACE WITH THE PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510605_1 CDM 444 RC 92608 HCPCS outpatient 236 177 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 224.2 95 999999999 184.08 224.2 percent of total billed charges "EVALUATION FOR PRESCRIPTION FOR SPEECH-GENERATING AUGMENTATIVE AND ALTERNATIVE COMMUNICATION DEVICE, FACE-TO-FACE WITH THE PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510605_1 CDM 444 RC 92608 HCPCS outpatient 236 177 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 210.04 89 999999999 184.08 224.2 percent of total billed charges "EVALUATION FOR PRESCRIPTION FOR SPEECH-GENERATING AUGMENTATIVE AND ALTERNATIVE COMMUNICATION DEVICE, FACE-TO-FACE WITH THE PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510605_1 CDM 444 RC 92608 HCPCS outpatient 236 177 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 207.68 88 999999999 184.08 224.2 percent of total billed charges "EVALUATION FOR PRESCRIPTION FOR SPEECH-GENERATING AUGMENTATIVE AND ALTERNATIVE COMMUNICATION DEVICE, FACE-TO-FACE WITH THE PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9510605_1 CDM 444 RC 92608 HCPCS outpatient 236 177 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 210.04 89 999999999 184.08 224.2 percent of total billed charges EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION 9510607_1 CDM 444 RC 92610 HCPCS outpatient 356 267 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 320.4 90 999999999 277.68 338.2 percent of total billed charges EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION 9510607_1 CDM 444 RC 92610 HCPCS outpatient 356 267 AETNA MCR ADV AETNA MCR ADV 277.68 78 999999999 277.68 338.2 percent of total billed charges EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION 9510607_1 CDM 444 RC 92610 HCPCS outpatient 356 267 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 311.75 87.57 999999999 277.68 338.2 percent of total billed charges EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION 9510607_1 CDM 444 RC 92610 HCPCS outpatient 356 267 COORDINATED CARE MCAID COORDINATED CARE MCAID 302.85 85.07 999999999 277.68 338.2 percent of total billed charges EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION 9510607_1 CDM 444 RC 92610 HCPCS outpatient 356 267 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 302.85 85.07 999999999 277.68 338.2 percent of total billed charges EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION 9510607_1 CDM 444 RC 92610 HCPCS outpatient 356 267 MOLINA MCAID MOLINA MCAID 296.9 83.4 999999999 277.68 338.2 percent of total billed charges EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION 9510607_1 CDM 444 RC 92610 HCPCS outpatient 356 267 MOLINA MCR ADV MOLINA MCR ADV 316.84 89 999999999 277.68 338.2 percent of total billed charges EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION 9510607_1 CDM 444 RC 92610 HCPCS outpatient 356 267 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 316.84 89 999999999 277.68 338.2 percent of total billed charges EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION 9510607_1 CDM 444 RC 92610 HCPCS outpatient 356 267 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 316.84 89 999999999 277.68 338.2 percent of total billed charges EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION 9510607_1 CDM 444 RC 92610 HCPCS outpatient 356 267 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 320.4 90 999999999 277.68 338.2 percent of total billed charges EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION 9510607_1 CDM 444 RC 92610 HCPCS outpatient 356 267 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 338.2 95 999999999 277.68 338.2 percent of total billed charges EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION 9510607_1 CDM 444 RC 92610 HCPCS outpatient 356 267 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 338.2 95 999999999 277.68 338.2 percent of total billed charges EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION 9510607_1 CDM 444 RC 92610 HCPCS outpatient 356 267 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 316.84 89 999999999 277.68 338.2 percent of total billed charges EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION 9510607_1 CDM 444 RC 92610 HCPCS outpatient 356 267 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 313.28 88 999999999 277.68 338.2 percent of total billed charges EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION 9510607_1 CDM 444 RC 92610 HCPCS outpatient 356 267 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 316.84 89 999999999 277.68 338.2 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY" 9510656_1 CDM 430 RC 97110 HCPCS outpatient 106 79.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 95.4 90 999999999 82.68 100.7 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY" 9510656_1 CDM 430 RC 97110 HCPCS outpatient 106 79.5 AETNA MCR ADV AETNA MCR ADV 82.68 78 999999999 82.68 100.7 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY" 9510656_1 CDM 430 RC 97110 HCPCS outpatient 106 79.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 92.82 87.57 999999999 82.68 100.7 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY" 9510656_1 CDM 430 RC 97110 HCPCS outpatient 106 79.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 90.17 85.07 999999999 82.68 100.7 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY" 9510656_1 CDM 430 RC 97110 HCPCS outpatient 106 79.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 90.17 85.07 999999999 82.68 100.7 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY" 9510656_1 CDM 430 RC 97110 HCPCS outpatient 106 79.5 MOLINA MCAID MOLINA MCAID 88.4 83.4 999999999 82.68 100.7 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY" 9510656_1 CDM 430 RC 97110 HCPCS outpatient 106 79.5 MOLINA MCR ADV MOLINA MCR ADV 94.34 89 999999999 82.68 100.7 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY" 9510656_1 CDM 430 RC 97110 HCPCS outpatient 106 79.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 94.34 89 999999999 82.68 100.7 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY" 9510656_1 CDM 430 RC 97110 HCPCS outpatient 106 79.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 94.34 89 999999999 82.68 100.7 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY" 9510656_1 CDM 430 RC 97110 HCPCS outpatient 106 79.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 95.4 90 999999999 82.68 100.7 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY" 9510656_1 CDM 430 RC 97110 HCPCS outpatient 106 79.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 100.7 95 999999999 82.68 100.7 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY" 9510656_1 CDM 430 RC 97110 HCPCS outpatient 106 79.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 100.7 95 999999999 82.68 100.7 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY" 9510656_1 CDM 430 RC 97110 HCPCS outpatient 106 79.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 94.34 89 999999999 82.68 100.7 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY" 9510656_1 CDM 430 RC 97110 HCPCS outpatient 106 79.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 93.28 88 999999999 82.68 100.7 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY" 9510656_1 CDM 430 RC 97110 HCPCS outpatient 106 79.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 94.34 89 999999999 82.68 100.7 percent of total billed charges "ARTERIAL PUNCTURE, WITHDRAWAL OF BLOOD FOR DIAGNOSIS" 9510725_1 CDM 920 RC 36600 HCPCS outpatient 248 186 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 223.2 999999999 193.44 235.6 case rate "ARTERIAL PUNCTURE, WITHDRAWAL OF BLOOD FOR DIAGNOSIS" 9510725_1 CDM 920 RC 36600 HCPCS outpatient 248 186 AETNA MCR ADV AETNA MCR ADV 193.44 78 999999999 193.44 235.6 percent of total billed charges "ARTERIAL PUNCTURE, WITHDRAWAL OF BLOOD FOR DIAGNOSIS" 9510725_1 CDM 920 RC 36600 HCPCS outpatient 248 186 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 217.17 87.57 999999999 193.44 235.6 percent of total billed charges "ARTERIAL PUNCTURE, WITHDRAWAL OF BLOOD FOR DIAGNOSIS" 9510725_1 CDM 920 RC 36600 HCPCS outpatient 248 186 COORDINATED CARE MCAID COORDINATED CARE MCAID 210.97 85.07 999999999 193.44 235.6 percent of total billed charges "ARTERIAL PUNCTURE, WITHDRAWAL OF BLOOD FOR DIAGNOSIS" 9510725_1 CDM 920 RC 36600 HCPCS outpatient 248 186 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 210.97 85.07 999999999 193.44 235.6 percent of total billed charges "ARTERIAL PUNCTURE, WITHDRAWAL OF BLOOD FOR DIAGNOSIS" 9510725_1 CDM 920 RC 36600 HCPCS outpatient 248 186 MOLINA MCAID MOLINA MCAID 206.83 83.4 999999999 193.44 235.6 percent of total billed charges "ARTERIAL PUNCTURE, WITHDRAWAL OF BLOOD FOR DIAGNOSIS" 9510725_1 CDM 920 RC 36600 HCPCS outpatient 248 186 MOLINA MCR ADV MOLINA MCR ADV 220.72 89 999999999 193.44 235.6 percent of total billed charges "ARTERIAL PUNCTURE, WITHDRAWAL OF BLOOD FOR DIAGNOSIS" 9510725_1 CDM 920 RC 36600 HCPCS outpatient 248 186 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 220.72 89 999999999 193.44 235.6 percent of total billed charges "ARTERIAL PUNCTURE, WITHDRAWAL OF BLOOD FOR DIAGNOSIS" 9510725_1 CDM 920 RC 36600 HCPCS outpatient 248 186 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 220.72 89 999999999 193.44 235.6 percent of total billed charges "ARTERIAL PUNCTURE, WITHDRAWAL OF BLOOD FOR DIAGNOSIS" 9510725_1 CDM 920 RC 36600 HCPCS outpatient 248 186 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 223.2 90 999999999 193.44 235.6 percent of total billed charges "ARTERIAL PUNCTURE, WITHDRAWAL OF BLOOD FOR DIAGNOSIS" 9510725_1 CDM 920 RC 36600 HCPCS outpatient 248 186 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 235.6 95 999999999 193.44 235.6 percent of total billed charges "ARTERIAL PUNCTURE, WITHDRAWAL OF BLOOD FOR DIAGNOSIS" 9510725_1 CDM 920 RC 36600 HCPCS outpatient 248 186 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 235.6 95 999999999 193.44 235.6 percent of total billed charges "ARTERIAL PUNCTURE, WITHDRAWAL OF BLOOD FOR DIAGNOSIS" 9510725_1 CDM 920 RC 36600 HCPCS outpatient 248 186 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 220.72 89 999999999 193.44 235.6 percent of total billed charges "ARTERIAL PUNCTURE, WITHDRAWAL OF BLOOD FOR DIAGNOSIS" 9510725_1 CDM 920 RC 36600 HCPCS outpatient 248 186 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 218.24 88 999999999 193.44 235.6 percent of total billed charges "ARTERIAL PUNCTURE, WITHDRAWAL OF BLOOD FOR DIAGNOSIS" 9510725_1 CDM 920 RC 36600 HCPCS outpatient 248 186 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 220.72 89 999999999 193.44 235.6 percent of total billed charges NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION; SINGLE DETERMINATION 9510766_1 CDM 460 RC 94760 HCPCS outpatient 92 69 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 82.8 90 999999999 71.76 87.4 percent of total billed charges NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION; SINGLE DETERMINATION 9510766_1 CDM 460 RC 94760 HCPCS outpatient 92 69 AETNA MCR ADV AETNA MCR ADV 71.76 78 999999999 71.76 87.4 percent of total billed charges NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION; SINGLE DETERMINATION 9510766_1 CDM 460 RC 94760 HCPCS outpatient 92 69 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 80.56 87.57 999999999 71.76 87.4 percent of total billed charges NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION; SINGLE DETERMINATION 9510766_1 CDM 460 RC 94760 HCPCS outpatient 92 69 COORDINATED CARE MCAID COORDINATED CARE MCAID 78.26 85.07 999999999 71.76 87.4 percent of total billed charges NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION; SINGLE DETERMINATION 9510766_1 CDM 460 RC 94760 HCPCS outpatient 92 69 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 78.26 85.07 999999999 71.76 87.4 percent of total billed charges NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION; SINGLE DETERMINATION 9510766_1 CDM 460 RC 94760 HCPCS outpatient 92 69 MOLINA MCAID MOLINA MCAID 76.73 83.4 999999999 71.76 87.4 percent of total billed charges NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION; SINGLE DETERMINATION 9510766_1 CDM 460 RC 94760 HCPCS outpatient 92 69 MOLINA MCR ADV MOLINA MCR ADV 81.88 89 999999999 71.76 87.4 percent of total billed charges NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION; SINGLE DETERMINATION 9510766_1 CDM 460 RC 94760 HCPCS outpatient 92 69 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 81.88 89 999999999 71.76 87.4 percent of total billed charges NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION; SINGLE DETERMINATION 9510766_1 CDM 460 RC 94760 HCPCS outpatient 92 69 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 81.88 89 999999999 71.76 87.4 percent of total billed charges NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION; SINGLE DETERMINATION 9510766_1 CDM 460 RC 94760 HCPCS outpatient 92 69 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 82.8 90 999999999 71.76 87.4 percent of total billed charges NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION; SINGLE DETERMINATION 9510766_1 CDM 460 RC 94760 HCPCS outpatient 92 69 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 87.4 95 999999999 71.76 87.4 percent of total billed charges NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION; SINGLE DETERMINATION 9510766_1 CDM 460 RC 94760 HCPCS outpatient 92 69 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 87.4 95 999999999 71.76 87.4 percent of total billed charges NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION; SINGLE DETERMINATION 9510766_1 CDM 460 RC 94760 HCPCS outpatient 92 69 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 81.88 89 999999999 71.76 87.4 percent of total billed charges NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION; SINGLE DETERMINATION 9510766_1 CDM 460 RC 94760 HCPCS outpatient 92 69 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 80.96 88 999999999 71.76 87.4 percent of total billed charges NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION; SINGLE DETERMINATION 9510766_1 CDM 460 RC 94760 HCPCS outpatient 92 69 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 81.88 89 999999999 71.76 87.4 percent of total billed charges "BRONCHODILATION RESPONSIVENESS, SPIROMETRY AS IN 94010, PRE- AND POST-BRONCHODILATOR ADMINISTRATION" 9510777_1 CDM 460 RC 94060 HCPCS outpatient 445 333.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 400.5 90 999999999 347.1 422.75 percent of total billed charges "BRONCHODILATION RESPONSIVENESS, SPIROMETRY AS IN 94010, PRE- AND POST-BRONCHODILATOR ADMINISTRATION" 9510777_1 CDM 460 RC 94060 HCPCS outpatient 445 333.75 AETNA MCR ADV AETNA MCR ADV 347.1 78 999999999 347.1 422.75 percent of total billed charges "BRONCHODILATION RESPONSIVENESS, SPIROMETRY AS IN 94010, PRE- AND POST-BRONCHODILATOR ADMINISTRATION" 9510777_1 CDM 460 RC 94060 HCPCS outpatient 445 333.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 389.69 87.57 999999999 347.1 422.75 percent of total billed charges "BRONCHODILATION RESPONSIVENESS, SPIROMETRY AS IN 94010, PRE- AND POST-BRONCHODILATOR ADMINISTRATION" 9510777_1 CDM 460 RC 94060 HCPCS outpatient 445 333.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 378.56 85.07 999999999 347.1 422.75 percent of total billed charges "BRONCHODILATION RESPONSIVENESS, SPIROMETRY AS IN 94010, PRE- AND POST-BRONCHODILATOR ADMINISTRATION" 9510777_1 CDM 460 RC 94060 HCPCS outpatient 445 333.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 378.56 85.07 999999999 347.1 422.75 percent of total billed charges "BRONCHODILATION RESPONSIVENESS, SPIROMETRY AS IN 94010, PRE- AND POST-BRONCHODILATOR ADMINISTRATION" 9510777_1 CDM 460 RC 94060 HCPCS outpatient 445 333.75 MOLINA MCAID MOLINA MCAID 371.13 83.4 999999999 347.1 422.75 percent of total billed charges "BRONCHODILATION RESPONSIVENESS, SPIROMETRY AS IN 94010, PRE- AND POST-BRONCHODILATOR ADMINISTRATION" 9510777_1 CDM 460 RC 94060 HCPCS outpatient 445 333.75 MOLINA MCR ADV MOLINA MCR ADV 396.05 89 999999999 347.1 422.75 percent of total billed charges "BRONCHODILATION RESPONSIVENESS, SPIROMETRY AS IN 94010, PRE- AND POST-BRONCHODILATOR ADMINISTRATION" 9510777_1 CDM 460 RC 94060 HCPCS outpatient 445 333.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 396.05 89 999999999 347.1 422.75 percent of total billed charges "BRONCHODILATION RESPONSIVENESS, SPIROMETRY AS IN 94010, PRE- AND POST-BRONCHODILATOR ADMINISTRATION" 9510777_1 CDM 460 RC 94060 HCPCS outpatient 445 333.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 396.05 89 999999999 347.1 422.75 percent of total billed charges "BRONCHODILATION RESPONSIVENESS, SPIROMETRY AS IN 94010, PRE- AND POST-BRONCHODILATOR ADMINISTRATION" 9510777_1 CDM 460 RC 94060 HCPCS outpatient 445 333.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 400.5 90 999999999 347.1 422.75 percent of total billed charges "BRONCHODILATION RESPONSIVENESS, SPIROMETRY AS IN 94010, PRE- AND POST-BRONCHODILATOR ADMINISTRATION" 9510777_1 CDM 460 RC 94060 HCPCS outpatient 445 333.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 422.75 95 999999999 347.1 422.75 percent of total billed charges "BRONCHODILATION RESPONSIVENESS, SPIROMETRY AS IN 94010, PRE- AND POST-BRONCHODILATOR ADMINISTRATION" 9510777_1 CDM 460 RC 94060 HCPCS outpatient 445 333.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 422.75 95 999999999 347.1 422.75 percent of total billed charges "BRONCHODILATION RESPONSIVENESS, SPIROMETRY AS IN 94010, PRE- AND POST-BRONCHODILATOR ADMINISTRATION" 9510777_1 CDM 460 RC 94060 HCPCS outpatient 445 333.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 396.05 89 999999999 347.1 422.75 percent of total billed charges "BRONCHODILATION RESPONSIVENESS, SPIROMETRY AS IN 94010, PRE- AND POST-BRONCHODILATOR ADMINISTRATION" 9510777_1 CDM 460 RC 94060 HCPCS outpatient 445 333.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 391.6 88 999999999 347.1 422.75 percent of total billed charges "BRONCHODILATION RESPONSIVENESS, SPIROMETRY AS IN 94010, PRE- AND POST-BRONCHODILATOR ADMINISTRATION" 9510777_1 CDM 460 RC 94060 HCPCS outpatient 445 333.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 396.05 89 999999999 347.1 422.75 percent of total billed charges "SPIROMETRY, INCLUDING GRAPHIC RECORD, TOTAL AND TIMED VITAL CAPACITY, EXPIRATORY FLOW RATE MEASUREMENT(S), WITH OR WITHOUT MAXIMAL VOLUNTARY VENTILATION" 9510779_1 CDM 460 RC 94010 HCPCS outpatient 241 180.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 216.9 90 999999999 187.98 228.95 percent of total billed charges "SPIROMETRY, INCLUDING GRAPHIC RECORD, TOTAL AND TIMED VITAL CAPACITY, EXPIRATORY FLOW RATE MEASUREMENT(S), WITH OR WITHOUT MAXIMAL VOLUNTARY VENTILATION" 9510779_1 CDM 460 RC 94010 HCPCS outpatient 241 180.75 AETNA MCR ADV AETNA MCR ADV 187.98 78 999999999 187.98 228.95 percent of total billed charges "SPIROMETRY, INCLUDING GRAPHIC RECORD, TOTAL AND TIMED VITAL CAPACITY, EXPIRATORY FLOW RATE MEASUREMENT(S), WITH OR WITHOUT MAXIMAL VOLUNTARY VENTILATION" 9510779_1 CDM 460 RC 94010 HCPCS outpatient 241 180.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 211.04 87.57 999999999 187.98 228.95 percent of total billed charges "SPIROMETRY, INCLUDING GRAPHIC RECORD, TOTAL AND TIMED VITAL CAPACITY, EXPIRATORY FLOW RATE MEASUREMENT(S), WITH OR WITHOUT MAXIMAL VOLUNTARY VENTILATION" 9510779_1 CDM 460 RC 94010 HCPCS outpatient 241 180.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 205.02 85.07 999999999 187.98 228.95 percent of total billed charges "SPIROMETRY, INCLUDING GRAPHIC RECORD, TOTAL AND TIMED VITAL CAPACITY, EXPIRATORY FLOW RATE MEASUREMENT(S), WITH OR WITHOUT MAXIMAL VOLUNTARY VENTILATION" 9510779_1 CDM 460 RC 94010 HCPCS outpatient 241 180.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 205.02 85.07 999999999 187.98 228.95 percent of total billed charges "SPIROMETRY, INCLUDING GRAPHIC RECORD, TOTAL AND TIMED VITAL CAPACITY, EXPIRATORY FLOW RATE MEASUREMENT(S), WITH OR WITHOUT MAXIMAL VOLUNTARY VENTILATION" 9510779_1 CDM 460 RC 94010 HCPCS outpatient 241 180.75 MOLINA MCAID MOLINA MCAID 200.99 83.4 999999999 187.98 228.95 percent of total billed charges "SPIROMETRY, INCLUDING GRAPHIC RECORD, TOTAL AND TIMED VITAL CAPACITY, EXPIRATORY FLOW RATE MEASUREMENT(S), WITH OR WITHOUT MAXIMAL VOLUNTARY VENTILATION" 9510779_1 CDM 460 RC 94010 HCPCS outpatient 241 180.75 MOLINA MCR ADV MOLINA MCR ADV 214.49 89 999999999 187.98 228.95 percent of total billed charges "SPIROMETRY, INCLUDING GRAPHIC RECORD, TOTAL AND TIMED VITAL CAPACITY, EXPIRATORY FLOW RATE MEASUREMENT(S), WITH OR WITHOUT MAXIMAL VOLUNTARY VENTILATION" 9510779_1 CDM 460 RC 94010 HCPCS outpatient 241 180.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 214.49 89 999999999 187.98 228.95 percent of total billed charges "SPIROMETRY, INCLUDING GRAPHIC RECORD, TOTAL AND TIMED VITAL CAPACITY, EXPIRATORY FLOW RATE MEASUREMENT(S), WITH OR WITHOUT MAXIMAL VOLUNTARY VENTILATION" 9510779_1 CDM 460 RC 94010 HCPCS outpatient 241 180.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 214.49 89 999999999 187.98 228.95 percent of total billed charges "SPIROMETRY, INCLUDING GRAPHIC RECORD, TOTAL AND TIMED VITAL CAPACITY, EXPIRATORY FLOW RATE MEASUREMENT(S), WITH OR WITHOUT MAXIMAL VOLUNTARY VENTILATION" 9510779_1 CDM 460 RC 94010 HCPCS outpatient 241 180.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 216.9 90 999999999 187.98 228.95 percent of total billed charges "SPIROMETRY, INCLUDING GRAPHIC RECORD, TOTAL AND TIMED VITAL CAPACITY, EXPIRATORY FLOW RATE MEASUREMENT(S), WITH OR WITHOUT MAXIMAL VOLUNTARY VENTILATION" 9510779_1 CDM 460 RC 94010 HCPCS outpatient 241 180.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 228.95 95 999999999 187.98 228.95 percent of total billed charges "SPIROMETRY, INCLUDING GRAPHIC RECORD, TOTAL AND TIMED VITAL CAPACITY, EXPIRATORY FLOW RATE MEASUREMENT(S), WITH OR WITHOUT MAXIMAL VOLUNTARY VENTILATION" 9510779_1 CDM 460 RC 94010 HCPCS outpatient 241 180.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 228.95 95 999999999 187.98 228.95 percent of total billed charges "SPIROMETRY, INCLUDING GRAPHIC RECORD, TOTAL AND TIMED VITAL CAPACITY, EXPIRATORY FLOW RATE MEASUREMENT(S), WITH OR WITHOUT MAXIMAL VOLUNTARY VENTILATION" 9510779_1 CDM 460 RC 94010 HCPCS outpatient 241 180.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 214.49 89 999999999 187.98 228.95 percent of total billed charges "SPIROMETRY, INCLUDING GRAPHIC RECORD, TOTAL AND TIMED VITAL CAPACITY, EXPIRATORY FLOW RATE MEASUREMENT(S), WITH OR WITHOUT MAXIMAL VOLUNTARY VENTILATION" 9510779_1 CDM 460 RC 94010 HCPCS outpatient 241 180.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 212.08 88 999999999 187.98 228.95 percent of total billed charges "SPIROMETRY, INCLUDING GRAPHIC RECORD, TOTAL AND TIMED VITAL CAPACITY, EXPIRATORY FLOW RATE MEASUREMENT(S), WITH OR WITHOUT MAXIMAL VOLUNTARY VENTILATION" 9510779_1 CDM 460 RC 94010 HCPCS outpatient 241 180.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 214.49 89 999999999 187.98 228.95 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 9510782_1 CDM 410 RC 94640 HCPCS outpatient 375 281.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 337.5 90 999999999 292.5 356.25 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 9510782_1 CDM 410 RC 94640 HCPCS outpatient 375 281.25 AETNA MCR ADV AETNA MCR ADV 292.5 78 999999999 292.5 356.25 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 9510782_1 CDM 410 RC 94640 HCPCS outpatient 375 281.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 328.39 87.57 999999999 292.5 356.25 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 9510782_1 CDM 410 RC 94640 HCPCS outpatient 375 281.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 319.01 85.07 999999999 292.5 356.25 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 9510782_1 CDM 410 RC 94640 HCPCS outpatient 375 281.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 319.01 85.07 999999999 292.5 356.25 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 9510782_1 CDM 410 RC 94640 HCPCS outpatient 375 281.25 MOLINA MCAID MOLINA MCAID 312.75 83.4 999999999 292.5 356.25 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 9510782_1 CDM 410 RC 94640 HCPCS outpatient 375 281.25 MOLINA MCR ADV MOLINA MCR ADV 333.75 89 999999999 292.5 356.25 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 9510782_1 CDM 410 RC 94640 HCPCS outpatient 375 281.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 333.75 89 999999999 292.5 356.25 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 9510782_1 CDM 410 RC 94640 HCPCS outpatient 375 281.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 333.75 89 999999999 292.5 356.25 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 9510782_1 CDM 410 RC 94640 HCPCS outpatient 375 281.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 337.5 90 999999999 292.5 356.25 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 9510782_1 CDM 410 RC 94640 HCPCS outpatient 375 281.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 356.25 95 999999999 292.5 356.25 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 9510782_1 CDM 410 RC 94640 HCPCS outpatient 375 281.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 356.25 95 999999999 292.5 356.25 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 9510782_1 CDM 410 RC 94640 HCPCS outpatient 375 281.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 333.75 89 999999999 292.5 356.25 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 9510782_1 CDM 410 RC 94640 HCPCS outpatient 375 281.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 330 88 999999999 292.5 356.25 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 9510782_1 CDM 410 RC 94640 HCPCS outpatient 375 281.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 333.75 89 999999999 292.5 356.25 percent of total billed charges "APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ELECTRICAL STIMULATION (MANUAL), EACH 15 MINUTES" 9510790_1 CDM 420 RC 97032 HCPCS outpatient 76 57 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 68.4 90 999999999 59.28 72.2 percent of total billed charges "APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ELECTRICAL STIMULATION (MANUAL), EACH 15 MINUTES" 9510790_1 CDM 420 RC 97032 HCPCS outpatient 76 57 AETNA MCR ADV AETNA MCR ADV 59.28 78 999999999 59.28 72.2 percent of total billed charges "APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ELECTRICAL STIMULATION (MANUAL), EACH 15 MINUTES" 9510790_1 CDM 420 RC 97032 HCPCS outpatient 76 57 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 66.55 87.57 999999999 59.28 72.2 percent of total billed charges "APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ELECTRICAL STIMULATION (MANUAL), EACH 15 MINUTES" 9510790_1 CDM 420 RC 97032 HCPCS outpatient 76 57 COORDINATED CARE MCAID COORDINATED CARE MCAID 64.65 85.07 999999999 59.28 72.2 percent of total billed charges "APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ELECTRICAL STIMULATION (MANUAL), EACH 15 MINUTES" 9510790_1 CDM 420 RC 97032 HCPCS outpatient 76 57 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 64.65 85.07 999999999 59.28 72.2 percent of total billed charges "APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ELECTRICAL STIMULATION (MANUAL), EACH 15 MINUTES" 9510790_1 CDM 420 RC 97032 HCPCS outpatient 76 57 MOLINA MCAID MOLINA MCAID 63.38 83.4 999999999 59.28 72.2 percent of total billed charges "APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ELECTRICAL STIMULATION (MANUAL), EACH 15 MINUTES" 9510790_1 CDM 420 RC 97032 HCPCS outpatient 76 57 MOLINA MCR ADV MOLINA MCR ADV 67.64 89 999999999 59.28 72.2 percent of total billed charges "APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ELECTRICAL STIMULATION (MANUAL), EACH 15 MINUTES" 9510790_1 CDM 420 RC 97032 HCPCS outpatient 76 57 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 67.64 89 999999999 59.28 72.2 percent of total billed charges "APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ELECTRICAL STIMULATION (MANUAL), EACH 15 MINUTES" 9510790_1 CDM 420 RC 97032 HCPCS outpatient 76 57 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 67.64 89 999999999 59.28 72.2 percent of total billed charges "APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ELECTRICAL STIMULATION (MANUAL), EACH 15 MINUTES" 9510790_1 CDM 420 RC 97032 HCPCS outpatient 76 57 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 68.4 90 999999999 59.28 72.2 percent of total billed charges "APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ELECTRICAL STIMULATION (MANUAL), EACH 15 MINUTES" 9510790_1 CDM 420 RC 97032 HCPCS outpatient 76 57 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 72.2 95 999999999 59.28 72.2 percent of total billed charges "APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ELECTRICAL STIMULATION (MANUAL), EACH 15 MINUTES" 9510790_1 CDM 420 RC 97032 HCPCS outpatient 76 57 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 72.2 95 999999999 59.28 72.2 percent of total billed charges "APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ELECTRICAL STIMULATION (MANUAL), EACH 15 MINUTES" 9510790_1 CDM 420 RC 97032 HCPCS outpatient 76 57 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 67.64 89 999999999 59.28 72.2 percent of total billed charges "APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ELECTRICAL STIMULATION (MANUAL), EACH 15 MINUTES" 9510790_1 CDM 420 RC 97032 HCPCS outpatient 76 57 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 66.88 88 999999999 59.28 72.2 percent of total billed charges "APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ELECTRICAL STIMULATION (MANUAL), EACH 15 MINUTES" 9510790_1 CDM 420 RC 97032 HCPCS outpatient 76 57 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 67.64 89 999999999 59.28 72.2 percent of total billed charges APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ELECTRICAL STIMULATION (UNATTENDED) 9510791_1 CDM 420 RC 97014 HCPCS outpatient 79 59.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 71.1 90 999999999 61.62 75.05 percent of total billed charges APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ELECTRICAL STIMULATION (UNATTENDED) 9510791_1 CDM 420 RC 97014 HCPCS outpatient 79 59.25 AETNA MCR ADV AETNA MCR ADV 61.62 78 999999999 61.62 75.05 percent of total billed charges APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ELECTRICAL STIMULATION (UNATTENDED) 9510791_1 CDM 420 RC 97014 HCPCS outpatient 79 59.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 69.18 87.57 999999999 61.62 75.05 percent of total billed charges APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ELECTRICAL STIMULATION (UNATTENDED) 9510791_1 CDM 420 RC 97014 HCPCS outpatient 79 59.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 67.21 85.07 999999999 61.62 75.05 percent of total billed charges APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ELECTRICAL STIMULATION (UNATTENDED) 9510791_1 CDM 420 RC 97014 HCPCS outpatient 79 59.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 67.21 85.07 999999999 61.62 75.05 percent of total billed charges APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ELECTRICAL STIMULATION (UNATTENDED) 9510791_1 CDM 420 RC 97014 HCPCS outpatient 79 59.25 MOLINA MCAID MOLINA MCAID 65.89 83.4 999999999 61.62 75.05 percent of total billed charges APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ELECTRICAL STIMULATION (UNATTENDED) 9510791_1 CDM 420 RC 97014 HCPCS outpatient 79 59.25 MOLINA MCR ADV MOLINA MCR ADV 70.31 89 999999999 61.62 75.05 percent of total billed charges APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ELECTRICAL STIMULATION (UNATTENDED) 9510791_1 CDM 420 RC 97014 HCPCS outpatient 79 59.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 70.31 89 999999999 61.62 75.05 percent of total billed charges APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ELECTRICAL STIMULATION (UNATTENDED) 9510791_1 CDM 420 RC 97014 HCPCS outpatient 79 59.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 70.31 89 999999999 61.62 75.05 percent of total billed charges APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ELECTRICAL STIMULATION (UNATTENDED) 9510791_1 CDM 420 RC 97014 HCPCS outpatient 79 59.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 71.1 90 999999999 61.62 75.05 percent of total billed charges APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ELECTRICAL STIMULATION (UNATTENDED) 9510791_1 CDM 420 RC 97014 HCPCS outpatient 79 59.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 75.05 95 999999999 61.62 75.05 percent of total billed charges APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ELECTRICAL STIMULATION (UNATTENDED) 9510791_1 CDM 420 RC 97014 HCPCS outpatient 79 59.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 75.05 95 999999999 61.62 75.05 percent of total billed charges APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ELECTRICAL STIMULATION (UNATTENDED) 9510791_1 CDM 420 RC 97014 HCPCS outpatient 79 59.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 70.31 89 999999999 61.62 75.05 percent of total billed charges APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ELECTRICAL STIMULATION (UNATTENDED) 9510791_1 CDM 420 RC 97014 HCPCS outpatient 79 59.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 69.52 88 999999999 61.62 75.05 percent of total billed charges APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ELECTRICAL STIMULATION (UNATTENDED) 9510791_1 CDM 420 RC 97014 HCPCS outpatient 79 59.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 70.31 89 999999999 61.62 75.05 percent of total billed charges "THERAPEUTIC ACTIVITIES, DIRECT (ONE-ON-ONE) PATIENT CONTACT (USE OF DYNAMIC ACTIVITIES TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 MINUTES" 9510792_1 CDM 420 RC 97530 HCPCS outpatient 111 83.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 99.9 90 999999999 86.58 105.45 percent of total billed charges "THERAPEUTIC ACTIVITIES, DIRECT (ONE-ON-ONE) PATIENT CONTACT (USE OF DYNAMIC ACTIVITIES TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 MINUTES" 9510792_1 CDM 420 RC 97530 HCPCS outpatient 111 83.25 AETNA MCR ADV AETNA MCR ADV 86.58 78 999999999 86.58 105.45 percent of total billed charges "THERAPEUTIC ACTIVITIES, DIRECT (ONE-ON-ONE) PATIENT CONTACT (USE OF DYNAMIC ACTIVITIES TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 MINUTES" 9510792_1 CDM 420 RC 97530 HCPCS outpatient 111 83.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 97.2 87.57 999999999 86.58 105.45 percent of total billed charges "THERAPEUTIC ACTIVITIES, DIRECT (ONE-ON-ONE) PATIENT CONTACT (USE OF DYNAMIC ACTIVITIES TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 MINUTES" 9510792_1 CDM 420 RC 97530 HCPCS outpatient 111 83.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 94.43 85.07 999999999 86.58 105.45 percent of total billed charges "THERAPEUTIC ACTIVITIES, DIRECT (ONE-ON-ONE) PATIENT CONTACT (USE OF DYNAMIC ACTIVITIES TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 MINUTES" 9510792_1 CDM 420 RC 97530 HCPCS outpatient 111 83.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 94.43 85.07 999999999 86.58 105.45 percent of total billed charges "THERAPEUTIC ACTIVITIES, DIRECT (ONE-ON-ONE) PATIENT CONTACT (USE OF DYNAMIC ACTIVITIES TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 MINUTES" 9510792_1 CDM 420 RC 97530 HCPCS outpatient 111 83.25 MOLINA MCAID MOLINA MCAID 92.57 83.4 999999999 86.58 105.45 percent of total billed charges "THERAPEUTIC ACTIVITIES, DIRECT (ONE-ON-ONE) PATIENT CONTACT (USE OF DYNAMIC ACTIVITIES TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 MINUTES" 9510792_1 CDM 420 RC 97530 HCPCS outpatient 111 83.25 MOLINA MCR ADV MOLINA MCR ADV 98.79 89 999999999 86.58 105.45 percent of total billed charges "THERAPEUTIC ACTIVITIES, DIRECT (ONE-ON-ONE) PATIENT CONTACT (USE OF DYNAMIC ACTIVITIES TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 MINUTES" 9510792_1 CDM 420 RC 97530 HCPCS outpatient 111 83.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 98.79 89 999999999 86.58 105.45 percent of total billed charges "THERAPEUTIC ACTIVITIES, DIRECT (ONE-ON-ONE) PATIENT CONTACT (USE OF DYNAMIC ACTIVITIES TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 MINUTES" 9510792_1 CDM 420 RC 97530 HCPCS outpatient 111 83.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 98.79 89 999999999 86.58 105.45 percent of total billed charges "THERAPEUTIC ACTIVITIES, DIRECT (ONE-ON-ONE) PATIENT CONTACT (USE OF DYNAMIC ACTIVITIES TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 MINUTES" 9510792_1 CDM 420 RC 97530 HCPCS outpatient 111 83.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 99.9 90 999999999 86.58 105.45 percent of total billed charges "THERAPEUTIC ACTIVITIES, DIRECT (ONE-ON-ONE) PATIENT CONTACT (USE OF DYNAMIC ACTIVITIES TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 MINUTES" 9510792_1 CDM 420 RC 97530 HCPCS outpatient 111 83.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 105.45 95 999999999 86.58 105.45 percent of total billed charges "THERAPEUTIC ACTIVITIES, DIRECT (ONE-ON-ONE) PATIENT CONTACT (USE OF DYNAMIC ACTIVITIES TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 MINUTES" 9510792_1 CDM 420 RC 97530 HCPCS outpatient 111 83.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 105.45 95 999999999 86.58 105.45 percent of total billed charges "THERAPEUTIC ACTIVITIES, DIRECT (ONE-ON-ONE) PATIENT CONTACT (USE OF DYNAMIC ACTIVITIES TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 MINUTES" 9510792_1 CDM 420 RC 97530 HCPCS outpatient 111 83.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 98.79 89 999999999 86.58 105.45 percent of total billed charges "THERAPEUTIC ACTIVITIES, DIRECT (ONE-ON-ONE) PATIENT CONTACT (USE OF DYNAMIC ACTIVITIES TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 MINUTES" 9510792_1 CDM 420 RC 97530 HCPCS outpatient 111 83.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 97.68 88 999999999 86.58 105.45 percent of total billed charges "THERAPEUTIC ACTIVITIES, DIRECT (ONE-ON-ONE) PATIENT CONTACT (USE OF DYNAMIC ACTIVITIES TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 MINUTES" 9510792_1 CDM 420 RC 97530 HCPCS outpatient 111 83.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 98.79 89 999999999 86.58 105.45 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; GAIT TRAINING (INCLUDES STAIR CLIMBING)" 9510793_1 CDM 420 RC 97116 HCPCS outpatient 93 69.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 83.7 90 999999999 72.54 88.35 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; GAIT TRAINING (INCLUDES STAIR CLIMBING)" 9510793_1 CDM 420 RC 97116 HCPCS outpatient 93 69.75 AETNA MCR ADV AETNA MCR ADV 72.54 78 999999999 72.54 88.35 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; GAIT TRAINING (INCLUDES STAIR CLIMBING)" 9510793_1 CDM 420 RC 97116 HCPCS outpatient 93 69.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 81.44 87.57 999999999 72.54 88.35 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; GAIT TRAINING (INCLUDES STAIR CLIMBING)" 9510793_1 CDM 420 RC 97116 HCPCS outpatient 93 69.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 79.12 85.07 999999999 72.54 88.35 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; GAIT TRAINING (INCLUDES STAIR CLIMBING)" 9510793_1 CDM 420 RC 97116 HCPCS outpatient 93 69.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 79.12 85.07 999999999 72.54 88.35 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; GAIT TRAINING (INCLUDES STAIR CLIMBING)" 9510793_1 CDM 420 RC 97116 HCPCS outpatient 93 69.75 MOLINA MCAID MOLINA MCAID 77.56 83.4 999999999 72.54 88.35 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; GAIT TRAINING (INCLUDES STAIR CLIMBING)" 9510793_1 CDM 420 RC 97116 HCPCS outpatient 93 69.75 MOLINA MCR ADV MOLINA MCR ADV 82.77 89 999999999 72.54 88.35 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; GAIT TRAINING (INCLUDES STAIR CLIMBING)" 9510793_1 CDM 420 RC 97116 HCPCS outpatient 93 69.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 82.77 89 999999999 72.54 88.35 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; GAIT TRAINING (INCLUDES STAIR CLIMBING)" 9510793_1 CDM 420 RC 97116 HCPCS outpatient 93 69.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 82.77 89 999999999 72.54 88.35 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; GAIT TRAINING (INCLUDES STAIR CLIMBING)" 9510793_1 CDM 420 RC 97116 HCPCS outpatient 93 69.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 83.7 90 999999999 72.54 88.35 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; GAIT TRAINING (INCLUDES STAIR CLIMBING)" 9510793_1 CDM 420 RC 97116 HCPCS outpatient 93 69.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 88.35 95 999999999 72.54 88.35 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; GAIT TRAINING (INCLUDES STAIR CLIMBING)" 9510793_1 CDM 420 RC 97116 HCPCS outpatient 93 69.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 88.35 95 999999999 72.54 88.35 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; GAIT TRAINING (INCLUDES STAIR CLIMBING)" 9510793_1 CDM 420 RC 97116 HCPCS outpatient 93 69.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 82.77 89 999999999 72.54 88.35 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; GAIT TRAINING (INCLUDES STAIR CLIMBING)" 9510793_1 CDM 420 RC 97116 HCPCS outpatient 93 69.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 81.84 88 999999999 72.54 88.35 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; GAIT TRAINING (INCLUDES STAIR CLIMBING)" 9510793_1 CDM 420 RC 97116 HCPCS outpatient 93 69.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 82.77 89 999999999 72.54 88.35 percent of total billed charges "MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 MINUTES" 9510797_1 CDM 420 RC 97140 HCPCS outpatient 118 88.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 106.2 90 999999999 92.04 112.1 percent of total billed charges "MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 MINUTES" 9510797_1 CDM 420 RC 97140 HCPCS outpatient 118 88.5 AETNA MCR ADV AETNA MCR ADV 92.04 78 999999999 92.04 112.1 percent of total billed charges "MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 MINUTES" 9510797_1 CDM 420 RC 97140 HCPCS outpatient 118 88.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 103.33 87.57 999999999 92.04 112.1 percent of total billed charges "MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 MINUTES" 9510797_1 CDM 420 RC 97140 HCPCS outpatient 118 88.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 100.38 85.07 999999999 92.04 112.1 percent of total billed charges "MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 MINUTES" 9510797_1 CDM 420 RC 97140 HCPCS outpatient 118 88.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 100.38 85.07 999999999 92.04 112.1 percent of total billed charges "MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 MINUTES" 9510797_1 CDM 420 RC 97140 HCPCS outpatient 118 88.5 MOLINA MCAID MOLINA MCAID 98.41 83.4 999999999 92.04 112.1 percent of total billed charges "MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 MINUTES" 9510797_1 CDM 420 RC 97140 HCPCS outpatient 118 88.5 MOLINA MCR ADV MOLINA MCR ADV 105.02 89 999999999 92.04 112.1 percent of total billed charges "MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 MINUTES" 9510797_1 CDM 420 RC 97140 HCPCS outpatient 118 88.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 105.02 89 999999999 92.04 112.1 percent of total billed charges "MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 MINUTES" 9510797_1 CDM 420 RC 97140 HCPCS outpatient 118 88.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 105.02 89 999999999 92.04 112.1 percent of total billed charges "MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 MINUTES" 9510797_1 CDM 420 RC 97140 HCPCS outpatient 118 88.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 106.2 90 999999999 92.04 112.1 percent of total billed charges "MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 MINUTES" 9510797_1 CDM 420 RC 97140 HCPCS outpatient 118 88.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 112.1 95 999999999 92.04 112.1 percent of total billed charges "MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 MINUTES" 9510797_1 CDM 420 RC 97140 HCPCS outpatient 118 88.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 112.1 95 999999999 92.04 112.1 percent of total billed charges "MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 MINUTES" 9510797_1 CDM 420 RC 97140 HCPCS outpatient 118 88.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 105.02 89 999999999 92.04 112.1 percent of total billed charges "MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 MINUTES" 9510797_1 CDM 420 RC 97140 HCPCS outpatient 118 88.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 103.84 88 999999999 92.04 112.1 percent of total billed charges "MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 MINUTES" 9510797_1 CDM 420 RC 97140 HCPCS outpatient 118 88.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 105.02 89 999999999 92.04 112.1 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; MASSAGE, INCLUDING EFFLEURAGE, PETRISSAGE AND/OR TAPOTEMENT (STROKING, COMPRESSION, PERCUSSION)" 9510798_1 CDM 420 RC 97124 HCPCS outpatient 22 16.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 19.8 90 999999999 17.16 20.9 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; MASSAGE, INCLUDING EFFLEURAGE, PETRISSAGE AND/OR TAPOTEMENT (STROKING, COMPRESSION, PERCUSSION)" 9510798_1 CDM 420 RC 97124 HCPCS outpatient 22 16.5 AETNA MCR ADV AETNA MCR ADV 17.16 78 999999999 17.16 20.9 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; MASSAGE, INCLUDING EFFLEURAGE, PETRISSAGE AND/OR TAPOTEMENT (STROKING, COMPRESSION, PERCUSSION)" 9510798_1 CDM 420 RC 97124 HCPCS outpatient 22 16.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 19.27 87.57 999999999 17.16 20.9 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; MASSAGE, INCLUDING EFFLEURAGE, PETRISSAGE AND/OR TAPOTEMENT (STROKING, COMPRESSION, PERCUSSION)" 9510798_1 CDM 420 RC 97124 HCPCS outpatient 22 16.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 18.72 85.07 999999999 17.16 20.9 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; MASSAGE, INCLUDING EFFLEURAGE, PETRISSAGE AND/OR TAPOTEMENT (STROKING, COMPRESSION, PERCUSSION)" 9510798_1 CDM 420 RC 97124 HCPCS outpatient 22 16.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 18.72 85.07 999999999 17.16 20.9 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; MASSAGE, INCLUDING EFFLEURAGE, PETRISSAGE AND/OR TAPOTEMENT (STROKING, COMPRESSION, PERCUSSION)" 9510798_1 CDM 420 RC 97124 HCPCS outpatient 22 16.5 MOLINA MCAID MOLINA MCAID 18.35 83.4 999999999 17.16 20.9 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; MASSAGE, INCLUDING EFFLEURAGE, PETRISSAGE AND/OR TAPOTEMENT (STROKING, COMPRESSION, PERCUSSION)" 9510798_1 CDM 420 RC 97124 HCPCS outpatient 22 16.5 MOLINA MCR ADV MOLINA MCR ADV 19.58 89 999999999 17.16 20.9 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; MASSAGE, INCLUDING EFFLEURAGE, PETRISSAGE AND/OR TAPOTEMENT (STROKING, COMPRESSION, PERCUSSION)" 9510798_1 CDM 420 RC 97124 HCPCS outpatient 22 16.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 19.58 89 999999999 17.16 20.9 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; MASSAGE, INCLUDING EFFLEURAGE, PETRISSAGE AND/OR TAPOTEMENT (STROKING, COMPRESSION, PERCUSSION)" 9510798_1 CDM 420 RC 97124 HCPCS outpatient 22 16.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 19.58 89 999999999 17.16 20.9 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; MASSAGE, INCLUDING EFFLEURAGE, PETRISSAGE AND/OR TAPOTEMENT (STROKING, COMPRESSION, PERCUSSION)" 9510798_1 CDM 420 RC 97124 HCPCS outpatient 22 16.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 19.8 90 999999999 17.16 20.9 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; MASSAGE, INCLUDING EFFLEURAGE, PETRISSAGE AND/OR TAPOTEMENT (STROKING, COMPRESSION, PERCUSSION)" 9510798_1 CDM 420 RC 97124 HCPCS outpatient 22 16.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 20.9 95 999999999 17.16 20.9 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; MASSAGE, INCLUDING EFFLEURAGE, PETRISSAGE AND/OR TAPOTEMENT (STROKING, COMPRESSION, PERCUSSION)" 9510798_1 CDM 420 RC 97124 HCPCS outpatient 22 16.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 20.9 95 999999999 17.16 20.9 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; MASSAGE, INCLUDING EFFLEURAGE, PETRISSAGE AND/OR TAPOTEMENT (STROKING, COMPRESSION, PERCUSSION)" 9510798_1 CDM 420 RC 97124 HCPCS outpatient 22 16.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 19.58 89 999999999 17.16 20.9 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; MASSAGE, INCLUDING EFFLEURAGE, PETRISSAGE AND/OR TAPOTEMENT (STROKING, COMPRESSION, PERCUSSION)" 9510798_1 CDM 420 RC 97124 HCPCS outpatient 22 16.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 19.36 88 999999999 17.16 20.9 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; MASSAGE, INCLUDING EFFLEURAGE, PETRISSAGE AND/OR TAPOTEMENT (STROKING, COMPRESSION, PERCUSSION)" 9510798_1 CDM 420 RC 97124 HCPCS outpatient 22 16.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 19.58 89 999999999 17.16 20.9 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; NEUROMUSCULAR REEDUCATION OF MOVEMENT, BALANCE, COORDINATION, KINESTHETIC SENSE, POSTURE, AND/OR PROPRIOCEPTION FOR SITTING AND/OR STANDING ACTIVITIES" 9510799_1 CDM 420 RC 97112 HCPCS outpatient 109 81.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 98.1 90 999999999 85.02 103.55 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; NEUROMUSCULAR REEDUCATION OF MOVEMENT, BALANCE, COORDINATION, KINESTHETIC SENSE, POSTURE, AND/OR PROPRIOCEPTION FOR SITTING AND/OR STANDING ACTIVITIES" 9510799_1 CDM 420 RC 97112 HCPCS outpatient 109 81.75 AETNA MCR ADV AETNA MCR ADV 85.02 78 999999999 85.02 103.55 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; NEUROMUSCULAR REEDUCATION OF MOVEMENT, BALANCE, COORDINATION, KINESTHETIC SENSE, POSTURE, AND/OR PROPRIOCEPTION FOR SITTING AND/OR STANDING ACTIVITIES" 9510799_1 CDM 420 RC 97112 HCPCS outpatient 109 81.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 95.45 87.57 999999999 85.02 103.55 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; NEUROMUSCULAR REEDUCATION OF MOVEMENT, BALANCE, COORDINATION, KINESTHETIC SENSE, POSTURE, AND/OR PROPRIOCEPTION FOR SITTING AND/OR STANDING ACTIVITIES" 9510799_1 CDM 420 RC 97112 HCPCS outpatient 109 81.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 92.73 85.07 999999999 85.02 103.55 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; NEUROMUSCULAR REEDUCATION OF MOVEMENT, BALANCE, COORDINATION, KINESTHETIC SENSE, POSTURE, AND/OR PROPRIOCEPTION FOR SITTING AND/OR STANDING ACTIVITIES" 9510799_1 CDM 420 RC 97112 HCPCS outpatient 109 81.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 92.73 85.07 999999999 85.02 103.55 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; NEUROMUSCULAR REEDUCATION OF MOVEMENT, BALANCE, COORDINATION, KINESTHETIC SENSE, POSTURE, AND/OR PROPRIOCEPTION FOR SITTING AND/OR STANDING ACTIVITIES" 9510799_1 CDM 420 RC 97112 HCPCS outpatient 109 81.75 MOLINA MCAID MOLINA MCAID 90.91 83.4 999999999 85.02 103.55 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; NEUROMUSCULAR REEDUCATION OF MOVEMENT, BALANCE, COORDINATION, KINESTHETIC SENSE, POSTURE, AND/OR PROPRIOCEPTION FOR SITTING AND/OR STANDING ACTIVITIES" 9510799_1 CDM 420 RC 97112 HCPCS outpatient 109 81.75 MOLINA MCR ADV MOLINA MCR ADV 97.01 89 999999999 85.02 103.55 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; NEUROMUSCULAR REEDUCATION OF MOVEMENT, BALANCE, COORDINATION, KINESTHETIC SENSE, POSTURE, AND/OR PROPRIOCEPTION FOR SITTING AND/OR STANDING ACTIVITIES" 9510799_1 CDM 420 RC 97112 HCPCS outpatient 109 81.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 97.01 89 999999999 85.02 103.55 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; NEUROMUSCULAR REEDUCATION OF MOVEMENT, BALANCE, COORDINATION, KINESTHETIC SENSE, POSTURE, AND/OR PROPRIOCEPTION FOR SITTING AND/OR STANDING ACTIVITIES" 9510799_1 CDM 420 RC 97112 HCPCS outpatient 109 81.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 97.01 89 999999999 85.02 103.55 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; NEUROMUSCULAR REEDUCATION OF MOVEMENT, BALANCE, COORDINATION, KINESTHETIC SENSE, POSTURE, AND/OR PROPRIOCEPTION FOR SITTING AND/OR STANDING ACTIVITIES" 9510799_1 CDM 420 RC 97112 HCPCS outpatient 109 81.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 98.1 90 999999999 85.02 103.55 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; NEUROMUSCULAR REEDUCATION OF MOVEMENT, BALANCE, COORDINATION, KINESTHETIC SENSE, POSTURE, AND/OR PROPRIOCEPTION FOR SITTING AND/OR STANDING ACTIVITIES" 9510799_1 CDM 420 RC 97112 HCPCS outpatient 109 81.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 103.55 95 999999999 85.02 103.55 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; NEUROMUSCULAR REEDUCATION OF MOVEMENT, BALANCE, COORDINATION, KINESTHETIC SENSE, POSTURE, AND/OR PROPRIOCEPTION FOR SITTING AND/OR STANDING ACTIVITIES" 9510799_1 CDM 420 RC 97112 HCPCS outpatient 109 81.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 103.55 95 999999999 85.02 103.55 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; NEUROMUSCULAR REEDUCATION OF MOVEMENT, BALANCE, COORDINATION, KINESTHETIC SENSE, POSTURE, AND/OR PROPRIOCEPTION FOR SITTING AND/OR STANDING ACTIVITIES" 9510799_1 CDM 420 RC 97112 HCPCS outpatient 109 81.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 97.01 89 999999999 85.02 103.55 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; NEUROMUSCULAR REEDUCATION OF MOVEMENT, BALANCE, COORDINATION, KINESTHETIC SENSE, POSTURE, AND/OR PROPRIOCEPTION FOR SITTING AND/OR STANDING ACTIVITIES" 9510799_1 CDM 420 RC 97112 HCPCS outpatient 109 81.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 95.92 88 999999999 85.02 103.55 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; NEUROMUSCULAR REEDUCATION OF MOVEMENT, BALANCE, COORDINATION, KINESTHETIC SENSE, POSTURE, AND/OR PROPRIOCEPTION FOR SITTING AND/OR STANDING ACTIVITIES" 9510799_1 CDM 420 RC 97112 HCPCS outpatient 109 81.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 97.01 89 999999999 85.02 103.55 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY" 9510811_1 CDM 420 RC 97110 HCPCS outpatient 106 79.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 95.4 90 999999999 82.68 100.7 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY" 9510811_1 CDM 420 RC 97110 HCPCS outpatient 106 79.5 AETNA MCR ADV AETNA MCR ADV 82.68 78 999999999 82.68 100.7 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY" 9510811_1 CDM 420 RC 97110 HCPCS outpatient 106 79.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 92.82 87.57 999999999 82.68 100.7 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY" 9510811_1 CDM 420 RC 97110 HCPCS outpatient 106 79.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 90.17 85.07 999999999 82.68 100.7 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY" 9510811_1 CDM 420 RC 97110 HCPCS outpatient 106 79.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 90.17 85.07 999999999 82.68 100.7 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY" 9510811_1 CDM 420 RC 97110 HCPCS outpatient 106 79.5 MOLINA MCAID MOLINA MCAID 88.4 83.4 999999999 82.68 100.7 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY" 9510811_1 CDM 420 RC 97110 HCPCS outpatient 106 79.5 MOLINA MCR ADV MOLINA MCR ADV 94.34 89 999999999 82.68 100.7 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY" 9510811_1 CDM 420 RC 97110 HCPCS outpatient 106 79.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 94.34 89 999999999 82.68 100.7 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY" 9510811_1 CDM 420 RC 97110 HCPCS outpatient 106 79.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 94.34 89 999999999 82.68 100.7 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY" 9510811_1 CDM 420 RC 97110 HCPCS outpatient 106 79.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 95.4 90 999999999 82.68 100.7 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY" 9510811_1 CDM 420 RC 97110 HCPCS outpatient 106 79.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 100.7 95 999999999 82.68 100.7 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY" 9510811_1 CDM 420 RC 97110 HCPCS outpatient 106 79.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 100.7 95 999999999 82.68 100.7 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY" 9510811_1 CDM 420 RC 97110 HCPCS outpatient 106 79.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 94.34 89 999999999 82.68 100.7 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY" 9510811_1 CDM 420 RC 97110 HCPCS outpatient 106 79.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 93.28 88 999999999 82.68 100.7 percent of total billed charges "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY" 9510811_1 CDM 420 RC 97110 HCPCS outpatient 106 79.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 94.34 89 999999999 82.68 100.7 percent of total billed charges "APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ULTRASOUND, EACH 15 MINUTES" 9510814_1 CDM 420 RC 97035 HCPCS outpatient 71 53.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 63.9 90 999999999 55.38 67.45 percent of total billed charges "APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ULTRASOUND, EACH 15 MINUTES" 9510814_1 CDM 420 RC 97035 HCPCS outpatient 71 53.25 AETNA MCR ADV AETNA MCR ADV 55.38 78 999999999 55.38 67.45 percent of total billed charges "APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ULTRASOUND, EACH 15 MINUTES" 9510814_1 CDM 420 RC 97035 HCPCS outpatient 71 53.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 62.17 87.57 999999999 55.38 67.45 percent of total billed charges "APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ULTRASOUND, EACH 15 MINUTES" 9510814_1 CDM 420 RC 97035 HCPCS outpatient 71 53.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 60.4 85.07 999999999 55.38 67.45 percent of total billed charges "APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ULTRASOUND, EACH 15 MINUTES" 9510814_1 CDM 420 RC 97035 HCPCS outpatient 71 53.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 60.4 85.07 999999999 55.38 67.45 percent of total billed charges "APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ULTRASOUND, EACH 15 MINUTES" 9510814_1 CDM 420 RC 97035 HCPCS outpatient 71 53.25 MOLINA MCAID MOLINA MCAID 59.21 83.4 999999999 55.38 67.45 percent of total billed charges "APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ULTRASOUND, EACH 15 MINUTES" 9510814_1 CDM 420 RC 97035 HCPCS outpatient 71 53.25 MOLINA MCR ADV MOLINA MCR ADV 63.19 89 999999999 55.38 67.45 percent of total billed charges "APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ULTRASOUND, EACH 15 MINUTES" 9510814_1 CDM 420 RC 97035 HCPCS outpatient 71 53.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 63.19 89 999999999 55.38 67.45 percent of total billed charges "APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ULTRASOUND, EACH 15 MINUTES" 9510814_1 CDM 420 RC 97035 HCPCS outpatient 71 53.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 63.19 89 999999999 55.38 67.45 percent of total billed charges "APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ULTRASOUND, EACH 15 MINUTES" 9510814_1 CDM 420 RC 97035 HCPCS outpatient 71 53.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 63.9 90 999999999 55.38 67.45 percent of total billed charges "APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ULTRASOUND, EACH 15 MINUTES" 9510814_1 CDM 420 RC 97035 HCPCS outpatient 71 53.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 67.45 95 999999999 55.38 67.45 percent of total billed charges "APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ULTRASOUND, EACH 15 MINUTES" 9510814_1 CDM 420 RC 97035 HCPCS outpatient 71 53.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 67.45 95 999999999 55.38 67.45 percent of total billed charges "APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ULTRASOUND, EACH 15 MINUTES" 9510814_1 CDM 420 RC 97035 HCPCS outpatient 71 53.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 63.19 89 999999999 55.38 67.45 percent of total billed charges "APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ULTRASOUND, EACH 15 MINUTES" 9510814_1 CDM 420 RC 97035 HCPCS outpatient 71 53.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 62.48 88 999999999 55.38 67.45 percent of total billed charges "APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ULTRASOUND, EACH 15 MINUTES" 9510814_1 CDM 420 RC 97035 HCPCS outpatient 71 53.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 63.19 89 999999999 55.38 67.45 percent of total billed charges "SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING AND PROMOTE ADAPTIVE RESPONSES TO ENVIRONMENTAL DEMANDS, DIRECT (ONE-ON-ONE) PATIENT CONTACT, EACH 15 MINUTES" 9510839_1 CDM 430 RC 97533 HCPCS outpatient 102 76.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 91.8 90 999999999 79.56 96.9 percent of total billed charges "SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING AND PROMOTE ADAPTIVE RESPONSES TO ENVIRONMENTAL DEMANDS, DIRECT (ONE-ON-ONE) PATIENT CONTACT, EACH 15 MINUTES" 9510839_1 CDM 430 RC 97533 HCPCS outpatient 102 76.5 AETNA MCR ADV AETNA MCR ADV 79.56 78 999999999 79.56 96.9 percent of total billed charges "SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING AND PROMOTE ADAPTIVE RESPONSES TO ENVIRONMENTAL DEMANDS, DIRECT (ONE-ON-ONE) PATIENT CONTACT, EACH 15 MINUTES" 9510839_1 CDM 430 RC 97533 HCPCS outpatient 102 76.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 89.32 87.57 999999999 79.56 96.9 percent of total billed charges "SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING AND PROMOTE ADAPTIVE RESPONSES TO ENVIRONMENTAL DEMANDS, DIRECT (ONE-ON-ONE) PATIENT CONTACT, EACH 15 MINUTES" 9510839_1 CDM 430 RC 97533 HCPCS outpatient 102 76.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 86.77 85.07 999999999 79.56 96.9 percent of total billed charges "SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING AND PROMOTE ADAPTIVE RESPONSES TO ENVIRONMENTAL DEMANDS, DIRECT (ONE-ON-ONE) PATIENT CONTACT, EACH 15 MINUTES" 9510839_1 CDM 430 RC 97533 HCPCS outpatient 102 76.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 86.77 85.07 999999999 79.56 96.9 percent of total billed charges "SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING AND PROMOTE ADAPTIVE RESPONSES TO ENVIRONMENTAL DEMANDS, DIRECT (ONE-ON-ONE) PATIENT CONTACT, EACH 15 MINUTES" 9510839_1 CDM 430 RC 97533 HCPCS outpatient 102 76.5 MOLINA MCAID MOLINA MCAID 85.07 83.4 999999999 79.56 96.9 percent of total billed charges "SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING AND PROMOTE ADAPTIVE RESPONSES TO ENVIRONMENTAL DEMANDS, DIRECT (ONE-ON-ONE) PATIENT CONTACT, EACH 15 MINUTES" 9510839_1 CDM 430 RC 97533 HCPCS outpatient 102 76.5 MOLINA MCR ADV MOLINA MCR ADV 90.78 89 999999999 79.56 96.9 percent of total billed charges "SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING AND PROMOTE ADAPTIVE RESPONSES TO ENVIRONMENTAL DEMANDS, DIRECT (ONE-ON-ONE) PATIENT CONTACT, EACH 15 MINUTES" 9510839_1 CDM 430 RC 97533 HCPCS outpatient 102 76.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 90.78 89 999999999 79.56 96.9 percent of total billed charges "SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING AND PROMOTE ADAPTIVE RESPONSES TO ENVIRONMENTAL DEMANDS, DIRECT (ONE-ON-ONE) PATIENT CONTACT, EACH 15 MINUTES" 9510839_1 CDM 430 RC 97533 HCPCS outpatient 102 76.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 90.78 89 999999999 79.56 96.9 percent of total billed charges "SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING AND PROMOTE ADAPTIVE RESPONSES TO ENVIRONMENTAL DEMANDS, DIRECT (ONE-ON-ONE) PATIENT CONTACT, EACH 15 MINUTES" 9510839_1 CDM 430 RC 97533 HCPCS outpatient 102 76.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 91.8 90 999999999 79.56 96.9 percent of total billed charges "SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING AND PROMOTE ADAPTIVE RESPONSES TO ENVIRONMENTAL DEMANDS, DIRECT (ONE-ON-ONE) PATIENT CONTACT, EACH 15 MINUTES" 9510839_1 CDM 430 RC 97533 HCPCS outpatient 102 76.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 96.9 95 999999999 79.56 96.9 percent of total billed charges "SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING AND PROMOTE ADAPTIVE RESPONSES TO ENVIRONMENTAL DEMANDS, DIRECT (ONE-ON-ONE) PATIENT CONTACT, EACH 15 MINUTES" 9510839_1 CDM 430 RC 97533 HCPCS outpatient 102 76.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 96.9 95 999999999 79.56 96.9 percent of total billed charges "SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING AND PROMOTE ADAPTIVE RESPONSES TO ENVIRONMENTAL DEMANDS, DIRECT (ONE-ON-ONE) PATIENT CONTACT, EACH 15 MINUTES" 9510839_1 CDM 430 RC 97533 HCPCS outpatient 102 76.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 90.78 89 999999999 79.56 96.9 percent of total billed charges "SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING AND PROMOTE ADAPTIVE RESPONSES TO ENVIRONMENTAL DEMANDS, DIRECT (ONE-ON-ONE) PATIENT CONTACT, EACH 15 MINUTES" 9510839_1 CDM 430 RC 97533 HCPCS outpatient 102 76.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 89.76 88 999999999 79.56 96.9 percent of total billed charges "SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING AND PROMOTE ADAPTIVE RESPONSES TO ENVIRONMENTAL DEMANDS, DIRECT (ONE-ON-ONE) PATIENT CONTACT, EACH 15 MINUTES" 9510839_1 CDM 430 RC 97533 HCPCS outpatient 102 76.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 90.78 89 999999999 79.56 96.9 percent of total billed charges TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR FEEDING 9510850_1 CDM 440 RC 92526 HCPCS outpatient 263 197.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 236.7 90 999999999 205.14 249.85 percent of total billed charges TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR FEEDING 9510850_1 CDM 440 RC 92526 HCPCS outpatient 263 197.25 AETNA MCR ADV AETNA MCR ADV 205.14 78 999999999 205.14 249.85 percent of total billed charges TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR FEEDING 9510850_1 CDM 440 RC 92526 HCPCS outpatient 263 197.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 230.31 87.57 999999999 205.14 249.85 percent of total billed charges TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR FEEDING 9510850_1 CDM 440 RC 92526 HCPCS outpatient 263 197.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 223.73 85.07 999999999 205.14 249.85 percent of total billed charges TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR FEEDING 9510850_1 CDM 440 RC 92526 HCPCS outpatient 263 197.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 223.73 85.07 999999999 205.14 249.85 percent of total billed charges TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR FEEDING 9510850_1 CDM 440 RC 92526 HCPCS outpatient 263 197.25 MOLINA MCAID MOLINA MCAID 219.34 83.4 999999999 205.14 249.85 percent of total billed charges TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR FEEDING 9510850_1 CDM 440 RC 92526 HCPCS outpatient 263 197.25 MOLINA MCR ADV MOLINA MCR ADV 234.07 89 999999999 205.14 249.85 percent of total billed charges TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR FEEDING 9510850_1 CDM 440 RC 92526 HCPCS outpatient 263 197.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 234.07 89 999999999 205.14 249.85 percent of total billed charges TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR FEEDING 9510850_1 CDM 440 RC 92526 HCPCS outpatient 263 197.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 234.07 89 999999999 205.14 249.85 percent of total billed charges TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR FEEDING 9510850_1 CDM 440 RC 92526 HCPCS outpatient 263 197.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 236.7 90 999999999 205.14 249.85 percent of total billed charges TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR FEEDING 9510850_1 CDM 440 RC 92526 HCPCS outpatient 263 197.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 249.85 95 999999999 205.14 249.85 percent of total billed charges TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR FEEDING 9510850_1 CDM 440 RC 92526 HCPCS outpatient 263 197.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 249.85 95 999999999 205.14 249.85 percent of total billed charges TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR FEEDING 9510850_1 CDM 440 RC 92526 HCPCS outpatient 263 197.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 234.07 89 999999999 205.14 249.85 percent of total billed charges TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR FEEDING 9510850_1 CDM 440 RC 92526 HCPCS outpatient 263 197.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 231.44 88 999999999 205.14 249.85 percent of total billed charges TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR FEEDING 9510850_1 CDM 440 RC 92526 HCPCS outpatient 263 197.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 234.07 89 999999999 205.14 249.85 percent of total billed charges "THERAPEUTIC SERVICES FOR THE USE OF SPEECH-GENERATING DEVICE, INCLUDING PROGRAMMING AND MODIFICATION" 9510851_1 CDM 440 RC 92609 HCPCS outpatient 340 255 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 306 90 999999999 265.2 323 percent of total billed charges "THERAPEUTIC SERVICES FOR THE USE OF SPEECH-GENERATING DEVICE, INCLUDING PROGRAMMING AND MODIFICATION" 9510851_1 CDM 440 RC 92609 HCPCS outpatient 340 255 AETNA MCR ADV AETNA MCR ADV 265.2 78 999999999 265.2 323 percent of total billed charges "THERAPEUTIC SERVICES FOR THE USE OF SPEECH-GENERATING DEVICE, INCLUDING PROGRAMMING AND MODIFICATION" 9510851_1 CDM 440 RC 92609 HCPCS outpatient 340 255 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 297.74 87.57 999999999 265.2 323 percent of total billed charges "THERAPEUTIC SERVICES FOR THE USE OF SPEECH-GENERATING DEVICE, INCLUDING PROGRAMMING AND MODIFICATION" 9510851_1 CDM 440 RC 92609 HCPCS outpatient 340 255 COORDINATED CARE MCAID COORDINATED CARE MCAID 289.24 85.07 999999999 265.2 323 percent of total billed charges "THERAPEUTIC SERVICES FOR THE USE OF SPEECH-GENERATING DEVICE, INCLUDING PROGRAMMING AND MODIFICATION" 9510851_1 CDM 440 RC 92609 HCPCS outpatient 340 255 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 289.24 85.07 999999999 265.2 323 percent of total billed charges "THERAPEUTIC SERVICES FOR THE USE OF SPEECH-GENERATING DEVICE, INCLUDING PROGRAMMING AND MODIFICATION" 9510851_1 CDM 440 RC 92609 HCPCS outpatient 340 255 MOLINA MCAID MOLINA MCAID 283.56 83.4 999999999 265.2 323 percent of total billed charges "THERAPEUTIC SERVICES FOR THE USE OF SPEECH-GENERATING DEVICE, INCLUDING PROGRAMMING AND MODIFICATION" 9510851_1 CDM 440 RC 92609 HCPCS outpatient 340 255 MOLINA MCR ADV MOLINA MCR ADV 302.6 89 999999999 265.2 323 percent of total billed charges "THERAPEUTIC SERVICES FOR THE USE OF SPEECH-GENERATING DEVICE, INCLUDING PROGRAMMING AND MODIFICATION" 9510851_1 CDM 440 RC 92609 HCPCS outpatient 340 255 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 302.6 89 999999999 265.2 323 percent of total billed charges "THERAPEUTIC SERVICES FOR THE USE OF SPEECH-GENERATING DEVICE, INCLUDING PROGRAMMING AND MODIFICATION" 9510851_1 CDM 440 RC 92609 HCPCS outpatient 340 255 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 302.6 89 999999999 265.2 323 percent of total billed charges "THERAPEUTIC SERVICES FOR THE USE OF SPEECH-GENERATING DEVICE, INCLUDING PROGRAMMING AND MODIFICATION" 9510851_1 CDM 440 RC 92609 HCPCS outpatient 340 255 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 306 90 999999999 265.2 323 percent of total billed charges "THERAPEUTIC SERVICES FOR THE USE OF SPEECH-GENERATING DEVICE, INCLUDING PROGRAMMING AND MODIFICATION" 9510851_1 CDM 440 RC 92609 HCPCS outpatient 340 255 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 323 95 999999999 265.2 323 percent of total billed charges "THERAPEUTIC SERVICES FOR THE USE OF SPEECH-GENERATING DEVICE, INCLUDING PROGRAMMING AND MODIFICATION" 9510851_1 CDM 440 RC 92609 HCPCS outpatient 340 255 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 323 95 999999999 265.2 323 percent of total billed charges "THERAPEUTIC SERVICES FOR THE USE OF SPEECH-GENERATING DEVICE, INCLUDING PROGRAMMING AND MODIFICATION" 9510851_1 CDM 440 RC 92609 HCPCS outpatient 340 255 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 302.6 89 999999999 265.2 323 percent of total billed charges "THERAPEUTIC SERVICES FOR THE USE OF SPEECH-GENERATING DEVICE, INCLUDING PROGRAMMING AND MODIFICATION" 9510851_1 CDM 440 RC 92609 HCPCS outpatient 340 255 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 299.2 88 999999999 265.2 323 percent of total billed charges "THERAPEUTIC SERVICES FOR THE USE OF SPEECH-GENERATING DEVICE, INCLUDING PROGRAMMING AND MODIFICATION" 9510851_1 CDM 440 RC 92609 HCPCS outpatient 340 255 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 302.6 89 999999999 265.2 323 percent of total billed charges "TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR AUDITORY PROCESSING DISORDER; INDIVIDUAL" 9510852_1 CDM 440 RC 92507 HCPCS outpatient 258 193.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 232.2 90 999999999 201.24 245.1 percent of total billed charges "TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR AUDITORY PROCESSING DISORDER; INDIVIDUAL" 9510852_1 CDM 440 RC 92507 HCPCS outpatient 258 193.5 AETNA MCR ADV AETNA MCR ADV 201.24 78 999999999 201.24 245.1 percent of total billed charges "TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR AUDITORY PROCESSING DISORDER; INDIVIDUAL" 9510852_1 CDM 440 RC 92507 HCPCS outpatient 258 193.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 225.93 87.57 999999999 201.24 245.1 percent of total billed charges "TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR AUDITORY PROCESSING DISORDER; INDIVIDUAL" 9510852_1 CDM 440 RC 92507 HCPCS outpatient 258 193.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 219.48 85.07 999999999 201.24 245.1 percent of total billed charges "TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR AUDITORY PROCESSING DISORDER; INDIVIDUAL" 9510852_1 CDM 440 RC 92507 HCPCS outpatient 258 193.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 219.48 85.07 999999999 201.24 245.1 percent of total billed charges "TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR AUDITORY PROCESSING DISORDER; INDIVIDUAL" 9510852_1 CDM 440 RC 92507 HCPCS outpatient 258 193.5 MOLINA MCAID MOLINA MCAID 215.17 83.4 999999999 201.24 245.1 percent of total billed charges "TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR AUDITORY PROCESSING DISORDER; INDIVIDUAL" 9510852_1 CDM 440 RC 92507 HCPCS outpatient 258 193.5 MOLINA MCR ADV MOLINA MCR ADV 229.62 89 999999999 201.24 245.1 percent of total billed charges "TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR AUDITORY PROCESSING DISORDER; INDIVIDUAL" 9510852_1 CDM 440 RC 92507 HCPCS outpatient 258 193.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 229.62 89 999999999 201.24 245.1 percent of total billed charges "TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR AUDITORY PROCESSING DISORDER; INDIVIDUAL" 9510852_1 CDM 440 RC 92507 HCPCS outpatient 258 193.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 229.62 89 999999999 201.24 245.1 percent of total billed charges "TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR AUDITORY PROCESSING DISORDER; INDIVIDUAL" 9510852_1 CDM 440 RC 92507 HCPCS outpatient 258 193.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 232.2 90 999999999 201.24 245.1 percent of total billed charges "TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR AUDITORY PROCESSING DISORDER; INDIVIDUAL" 9510852_1 CDM 440 RC 92507 HCPCS outpatient 258 193.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 245.1 95 999999999 201.24 245.1 percent of total billed charges "TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR AUDITORY PROCESSING DISORDER; INDIVIDUAL" 9510852_1 CDM 440 RC 92507 HCPCS outpatient 258 193.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 245.1 95 999999999 201.24 245.1 percent of total billed charges "TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR AUDITORY PROCESSING DISORDER; INDIVIDUAL" 9510852_1 CDM 440 RC 92507 HCPCS outpatient 258 193.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 229.62 89 999999999 201.24 245.1 percent of total billed charges "TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR AUDITORY PROCESSING DISORDER; INDIVIDUAL" 9510852_1 CDM 440 RC 92507 HCPCS outpatient 258 193.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 227.04 88 999999999 201.24 245.1 percent of total billed charges "TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR AUDITORY PROCESSING DISORDER; INDIVIDUAL" 9510852_1 CDM 440 RC 92507 HCPCS outpatient 258 193.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 229.62 89 999999999 201.24 245.1 percent of total billed charges "TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR AUDITORY PROCESSING DISORDER; GROUP, 2 OR MORE INDIVIDUALS" 9510853_1 CDM 443 RC 92508 HCPCS outpatient 168 126 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 151.2 90 999999999 131.04 159.6 percent of total billed charges "TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR AUDITORY PROCESSING DISORDER; GROUP, 2 OR MORE INDIVIDUALS" 9510853_1 CDM 443 RC 92508 HCPCS outpatient 168 126 AETNA MCR ADV AETNA MCR ADV 131.04 78 999999999 131.04 159.6 percent of total billed charges "TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR AUDITORY PROCESSING DISORDER; GROUP, 2 OR MORE INDIVIDUALS" 9510853_1 CDM 443 RC 92508 HCPCS outpatient 168 126 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 147.12 87.57 999999999 131.04 159.6 percent of total billed charges "TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR AUDITORY PROCESSING DISORDER; GROUP, 2 OR MORE INDIVIDUALS" 9510853_1 CDM 443 RC 92508 HCPCS outpatient 168 126 COORDINATED CARE MCAID COORDINATED CARE MCAID 142.92 85.07 999999999 131.04 159.6 percent of total billed charges "TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR AUDITORY PROCESSING DISORDER; GROUP, 2 OR MORE INDIVIDUALS" 9510853_1 CDM 443 RC 92508 HCPCS outpatient 168 126 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 142.92 85.07 999999999 131.04 159.6 percent of total billed charges "TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR AUDITORY PROCESSING DISORDER; GROUP, 2 OR MORE INDIVIDUALS" 9510853_1 CDM 443 RC 92508 HCPCS outpatient 168 126 MOLINA MCAID MOLINA MCAID 140.11 83.4 999999999 131.04 159.6 percent of total billed charges "TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR AUDITORY PROCESSING DISORDER; GROUP, 2 OR MORE INDIVIDUALS" 9510853_1 CDM 443 RC 92508 HCPCS outpatient 168 126 MOLINA MCR ADV MOLINA MCR ADV 149.52 89 999999999 131.04 159.6 percent of total billed charges "TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR AUDITORY PROCESSING DISORDER; GROUP, 2 OR MORE INDIVIDUALS" 9510853_1 CDM 443 RC 92508 HCPCS outpatient 168 126 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 149.52 89 999999999 131.04 159.6 percent of total billed charges "TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR AUDITORY PROCESSING DISORDER; GROUP, 2 OR MORE INDIVIDUALS" 9510853_1 CDM 443 RC 92508 HCPCS outpatient 168 126 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 149.52 89 999999999 131.04 159.6 percent of total billed charges "TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR AUDITORY PROCESSING DISORDER; GROUP, 2 OR MORE INDIVIDUALS" 9510853_1 CDM 443 RC 92508 HCPCS outpatient 168 126 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 151.2 90 999999999 131.04 159.6 percent of total billed charges "TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR AUDITORY PROCESSING DISORDER; GROUP, 2 OR MORE INDIVIDUALS" 9510853_1 CDM 443 RC 92508 HCPCS outpatient 168 126 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 159.6 95 999999999 131.04 159.6 percent of total billed charges "TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR AUDITORY PROCESSING DISORDER; GROUP, 2 OR MORE INDIVIDUALS" 9510853_1 CDM 443 RC 92508 HCPCS outpatient 168 126 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 159.6 95 999999999 131.04 159.6 percent of total billed charges "TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR AUDITORY PROCESSING DISORDER; GROUP, 2 OR MORE INDIVIDUALS" 9510853_1 CDM 443 RC 92508 HCPCS outpatient 168 126 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 149.52 89 999999999 131.04 159.6 percent of total billed charges "TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR AUDITORY PROCESSING DISORDER; GROUP, 2 OR MORE INDIVIDUALS" 9510853_1 CDM 443 RC 92508 HCPCS outpatient 168 126 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 147.84 88 999999999 131.04 159.6 percent of total billed charges "TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR AUDITORY PROCESSING DISORDER; GROUP, 2 OR MORE INDIVIDUALS" 9510853_1 CDM 443 RC 92508 HCPCS outpatient 168 126 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 149.52 89 999999999 131.04 159.6 percent of total billed charges "SCREENING TEST, PURE TONE, AIR ONLY" 9510860_1 CDM 471 RC 92551 HCPCS outpatient 65 48.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 58.5 90 999999999 50.7 61.75 percent of total billed charges "SCREENING TEST, PURE TONE, AIR ONLY" 9510860_1 CDM 471 RC 92551 HCPCS outpatient 65 48.75 AETNA MCR ADV AETNA MCR ADV 50.7 78 999999999 50.7 61.75 percent of total billed charges "SCREENING TEST, PURE TONE, AIR ONLY" 9510860_1 CDM 471 RC 92551 HCPCS outpatient 65 48.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 56.92 87.57 999999999 50.7 61.75 percent of total billed charges "SCREENING TEST, PURE TONE, AIR ONLY" 9510860_1 CDM 471 RC 92551 HCPCS outpatient 65 48.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 55.3 85.07 999999999 50.7 61.75 percent of total billed charges "SCREENING TEST, PURE TONE, AIR ONLY" 9510860_1 CDM 471 RC 92551 HCPCS outpatient 65 48.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 55.3 85.07 999999999 50.7 61.75 percent of total billed charges "SCREENING TEST, PURE TONE, AIR ONLY" 9510860_1 CDM 471 RC 92551 HCPCS outpatient 65 48.75 MOLINA MCAID MOLINA MCAID 54.21 83.4 999999999 50.7 61.75 percent of total billed charges "SCREENING TEST, PURE TONE, AIR ONLY" 9510860_1 CDM 471 RC 92551 HCPCS outpatient 65 48.75 MOLINA MCR ADV MOLINA MCR ADV 57.85 89 999999999 50.7 61.75 percent of total billed charges "SCREENING TEST, PURE TONE, AIR ONLY" 9510860_1 CDM 471 RC 92551 HCPCS outpatient 65 48.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 57.85 89 999999999 50.7 61.75 percent of total billed charges "SCREENING TEST, PURE TONE, AIR ONLY" 9510860_1 CDM 471 RC 92551 HCPCS outpatient 65 48.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 57.85 89 999999999 50.7 61.75 percent of total billed charges "SCREENING TEST, PURE TONE, AIR ONLY" 9510860_1 CDM 471 RC 92551 HCPCS outpatient 65 48.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 58.5 90 999999999 50.7 61.75 percent of total billed charges "SCREENING TEST, PURE TONE, AIR ONLY" 9510860_1 CDM 471 RC 92551 HCPCS outpatient 65 48.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 61.75 95 999999999 50.7 61.75 percent of total billed charges "SCREENING TEST, PURE TONE, AIR ONLY" 9510860_1 CDM 471 RC 92551 HCPCS outpatient 65 48.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 61.75 95 999999999 50.7 61.75 percent of total billed charges "SCREENING TEST, PURE TONE, AIR ONLY" 9510860_1 CDM 471 RC 92551 HCPCS outpatient 65 48.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 57.85 89 999999999 50.7 61.75 percent of total billed charges "SCREENING TEST, PURE TONE, AIR ONLY" 9510860_1 CDM 471 RC 92551 HCPCS outpatient 65 48.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 57.2 88 999999999 50.7 61.75 percent of total billed charges "SCREENING TEST, PURE TONE, AIR ONLY" 9510860_1 CDM 471 RC 92551 HCPCS outpatient 65 48.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 57.85 89 999999999 50.7 61.75 percent of total billed charges EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT THAT MAY NOT REQUIRE THE PRESENCE OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL 9511003_1 CDM 450 RC 99281 HCPCS both 286 214.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 257.4 90 999999999 223.08 271.7 percent of total billed charges EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT THAT MAY NOT REQUIRE THE PRESENCE OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL 9511003_1 CDM 450 RC 99281 HCPCS both 286 214.5 AETNA MCR ADV AETNA MCR ADV 223.08 78 999999999 223.08 271.7 percent of total billed charges EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT THAT MAY NOT REQUIRE THE PRESENCE OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL 9511003_1 CDM 450 RC 99281 HCPCS both 286 214.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 250.45 87.57 999999999 223.08 271.7 percent of total billed charges EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT THAT MAY NOT REQUIRE THE PRESENCE OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL 9511003_1 CDM 450 RC 99281 HCPCS both 286 214.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 243.3 85.07 999999999 223.08 271.7 percent of total billed charges EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT THAT MAY NOT REQUIRE THE PRESENCE OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL 9511003_1 CDM 450 RC 99281 HCPCS both 286 214.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 243.3 85.07 999999999 223.08 271.7 percent of total billed charges EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT THAT MAY NOT REQUIRE THE PRESENCE OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL 9511003_1 CDM 450 RC 99281 HCPCS both 286 214.5 MOLINA MCAID MOLINA MCAID 238.52 83.4 999999999 223.08 271.7 percent of total billed charges EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT THAT MAY NOT REQUIRE THE PRESENCE OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL 9511003_1 CDM 450 RC 99281 HCPCS both 286 214.5 MOLINA MCR ADV MOLINA MCR ADV 254.54 89 999999999 223.08 271.7 percent of total billed charges EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT THAT MAY NOT REQUIRE THE PRESENCE OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL 9511003_1 CDM 450 RC 99281 HCPCS both 286 214.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 254.54 89 999999999 223.08 271.7 percent of total billed charges EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT THAT MAY NOT REQUIRE THE PRESENCE OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL 9511003_1 CDM 450 RC 99281 HCPCS both 286 214.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 254.54 89 999999999 223.08 271.7 percent of total billed charges EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT THAT MAY NOT REQUIRE THE PRESENCE OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL 9511003_1 CDM 450 RC 99281 HCPCS both 286 214.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 257.4 90 999999999 223.08 271.7 percent of total billed charges EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT THAT MAY NOT REQUIRE THE PRESENCE OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL 9511003_1 CDM 450 RC 99281 HCPCS both 286 214.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 271.7 95 999999999 223.08 271.7 percent of total billed charges EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT THAT MAY NOT REQUIRE THE PRESENCE OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL 9511003_1 CDM 450 RC 99281 HCPCS both 286 214.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 271.7 95 999999999 223.08 271.7 percent of total billed charges EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT THAT MAY NOT REQUIRE THE PRESENCE OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL 9511003_1 CDM 450 RC 99281 HCPCS both 286 214.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 254.54 89 999999999 223.08 271.7 percent of total billed charges EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT THAT MAY NOT REQUIRE THE PRESENCE OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL 9511003_1 CDM 450 RC 99281 HCPCS both 286 214.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 251.68 88 999999999 223.08 271.7 percent of total billed charges EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT THAT MAY NOT REQUIRE THE PRESENCE OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL 9511003_1 CDM 450 RC 99281 HCPCS both 286 214.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 254.54 89 999999999 223.08 271.7 percent of total billed charges EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT THAT MAY NOT REQUIRE THE PRESENCE OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL 9511003_2 CDM 450 RC 99281 HCPCS both 286 214.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 257.4 90 999999999 223.08 271.7 percent of total billed charges EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT THAT MAY NOT REQUIRE THE PRESENCE OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL 9511003_2 CDM 450 RC 99281 HCPCS both 286 214.5 AETNA MCR ADV AETNA MCR ADV 223.08 78 999999999 223.08 271.7 percent of total billed charges EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT THAT MAY NOT REQUIRE THE PRESENCE OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL 9511003_2 CDM 450 RC 99281 HCPCS both 286 214.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 250.45 87.57 999999999 223.08 271.7 percent of total billed charges EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT THAT MAY NOT REQUIRE THE PRESENCE OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL 9511003_2 CDM 450 RC 99281 HCPCS both 286 214.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 243.3 85.07 999999999 223.08 271.7 percent of total billed charges EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT THAT MAY NOT REQUIRE THE PRESENCE OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL 9511003_2 CDM 450 RC 99281 HCPCS both 286 214.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 243.3 85.07 999999999 223.08 271.7 percent of total billed charges EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT THAT MAY NOT REQUIRE THE PRESENCE OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL 9511003_2 CDM 450 RC 99281 HCPCS both 286 214.5 MOLINA MCAID MOLINA MCAID 238.52 83.4 999999999 223.08 271.7 percent of total billed charges EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT THAT MAY NOT REQUIRE THE PRESENCE OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL 9511003_2 CDM 450 RC 99281 HCPCS both 286 214.5 MOLINA MCR ADV MOLINA MCR ADV 254.54 89 999999999 223.08 271.7 percent of total billed charges EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT THAT MAY NOT REQUIRE THE PRESENCE OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL 9511003_2 CDM 450 RC 99281 HCPCS both 286 214.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 254.54 89 999999999 223.08 271.7 percent of total billed charges EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT THAT MAY NOT REQUIRE THE PRESENCE OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL 9511003_2 CDM 450 RC 99281 HCPCS both 286 214.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 254.54 89 999999999 223.08 271.7 percent of total billed charges EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT THAT MAY NOT REQUIRE THE PRESENCE OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL 9511003_2 CDM 450 RC 99281 HCPCS both 286 214.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 257.4 90 999999999 223.08 271.7 percent of total billed charges EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT THAT MAY NOT REQUIRE THE PRESENCE OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL 9511003_2 CDM 450 RC 99281 HCPCS both 286 214.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 271.7 95 999999999 223.08 271.7 percent of total billed charges EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT THAT MAY NOT REQUIRE THE PRESENCE OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL 9511003_2 CDM 450 RC 99281 HCPCS both 286 214.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 271.7 95 999999999 223.08 271.7 percent of total billed charges EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT THAT MAY NOT REQUIRE THE PRESENCE OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL 9511003_2 CDM 450 RC 99281 HCPCS both 286 214.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 254.54 89 999999999 223.08 271.7 percent of total billed charges EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT THAT MAY NOT REQUIRE THE PRESENCE OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL 9511003_2 CDM 450 RC 99281 HCPCS both 286 214.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 251.68 88 999999999 223.08 271.7 percent of total billed charges EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT THAT MAY NOT REQUIRE THE PRESENCE OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL 9511003_2 CDM 450 RC 99281 HCPCS both 286 214.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 254.54 89 999999999 223.08 271.7 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING" 9511004_1 CDM 450 RC 99282 HCPCS both 480 360 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 432 90 999999999 374.4 456 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING" 9511004_1 CDM 450 RC 99282 HCPCS both 480 360 AETNA MCR ADV AETNA MCR ADV 374.4 78 999999999 374.4 456 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING" 9511004_1 CDM 450 RC 99282 HCPCS both 480 360 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 420.34 87.57 999999999 374.4 456 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING" 9511004_1 CDM 450 RC 99282 HCPCS both 480 360 COORDINATED CARE MCAID COORDINATED CARE MCAID 408.34 85.07 999999999 374.4 456 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING" 9511004_1 CDM 450 RC 99282 HCPCS both 480 360 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 408.34 85.07 999999999 374.4 456 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING" 9511004_1 CDM 450 RC 99282 HCPCS both 480 360 MOLINA MCAID MOLINA MCAID 400.32 83.4 999999999 374.4 456 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING" 9511004_1 CDM 450 RC 99282 HCPCS both 480 360 MOLINA MCR ADV MOLINA MCR ADV 427.2 89 999999999 374.4 456 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING" 9511004_1 CDM 450 RC 99282 HCPCS both 480 360 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 427.2 89 999999999 374.4 456 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING" 9511004_1 CDM 450 RC 99282 HCPCS both 480 360 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 427.2 89 999999999 374.4 456 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING" 9511004_1 CDM 450 RC 99282 HCPCS both 480 360 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 432 90 999999999 374.4 456 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING" 9511004_1 CDM 450 RC 99282 HCPCS both 480 360 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 456 95 999999999 374.4 456 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING" 9511004_1 CDM 450 RC 99282 HCPCS both 480 360 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 456 95 999999999 374.4 456 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING" 9511004_1 CDM 450 RC 99282 HCPCS both 480 360 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 427.2 89 999999999 374.4 456 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING" 9511004_1 CDM 450 RC 99282 HCPCS both 480 360 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 422.4 88 999999999 374.4 456 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING" 9511004_1 CDM 450 RC 99282 HCPCS both 480 360 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 427.2 89 999999999 374.4 456 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING" 9511004_2 CDM 450 RC 99282 HCPCS both 480 360 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 432 90 999999999 374.4 456 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING" 9511004_2 CDM 450 RC 99282 HCPCS both 480 360 AETNA MCR ADV AETNA MCR ADV 374.4 78 999999999 374.4 456 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING" 9511004_2 CDM 450 RC 99282 HCPCS both 480 360 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 420.34 87.57 999999999 374.4 456 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING" 9511004_2 CDM 450 RC 99282 HCPCS both 480 360 COORDINATED CARE MCAID COORDINATED CARE MCAID 408.34 85.07 999999999 374.4 456 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING" 9511004_2 CDM 450 RC 99282 HCPCS both 480 360 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 408.34 85.07 999999999 374.4 456 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING" 9511004_2 CDM 450 RC 99282 HCPCS both 480 360 MOLINA MCAID MOLINA MCAID 400.32 83.4 999999999 374.4 456 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING" 9511004_2 CDM 450 RC 99282 HCPCS both 480 360 MOLINA MCR ADV MOLINA MCR ADV 427.2 89 999999999 374.4 456 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING" 9511004_2 CDM 450 RC 99282 HCPCS both 480 360 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 427.2 89 999999999 374.4 456 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING" 9511004_2 CDM 450 RC 99282 HCPCS both 480 360 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 427.2 89 999999999 374.4 456 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING" 9511004_2 CDM 450 RC 99282 HCPCS both 480 360 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 432 90 999999999 374.4 456 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING" 9511004_2 CDM 450 RC 99282 HCPCS both 480 360 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 456 95 999999999 374.4 456 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING" 9511004_2 CDM 450 RC 99282 HCPCS both 480 360 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 456 95 999999999 374.4 456 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING" 9511004_2 CDM 450 RC 99282 HCPCS both 480 360 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 427.2 89 999999999 374.4 456 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING" 9511004_2 CDM 450 RC 99282 HCPCS both 480 360 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 422.4 88 999999999 374.4 456 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING" 9511004_2 CDM 450 RC 99282 HCPCS both 480 360 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 427.2 89 999999999 374.4 456 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND LOW LEVEL OF MEDICAL DECISION MAKING" 9511005_1 CDM 450 RC 99283 HCPCS both 728 546 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 655.2 90 999999999 567.84 691.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND LOW LEVEL OF MEDICAL DECISION MAKING" 9511005_1 CDM 450 RC 99283 HCPCS both 728 546 AETNA MCR ADV AETNA MCR ADV 567.84 78 999999999 567.84 691.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND LOW LEVEL OF MEDICAL DECISION MAKING" 9511005_1 CDM 450 RC 99283 HCPCS both 728 546 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 637.51 87.57 999999999 567.84 691.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND LOW LEVEL OF MEDICAL DECISION MAKING" 9511005_1 CDM 450 RC 99283 HCPCS both 728 546 COORDINATED CARE MCAID COORDINATED CARE MCAID 619.31 85.07 999999999 567.84 691.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND LOW LEVEL OF MEDICAL DECISION MAKING" 9511005_1 CDM 450 RC 99283 HCPCS both 728 546 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 619.31 85.07 999999999 567.84 691.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND LOW LEVEL OF MEDICAL DECISION MAKING" 9511005_1 CDM 450 RC 99283 HCPCS both 728 546 MOLINA MCAID MOLINA MCAID 607.15 83.4 999999999 567.84 691.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND LOW LEVEL OF MEDICAL DECISION MAKING" 9511005_1 CDM 450 RC 99283 HCPCS both 728 546 MOLINA MCR ADV MOLINA MCR ADV 647.92 89 999999999 567.84 691.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND LOW LEVEL OF MEDICAL DECISION MAKING" 9511005_1 CDM 450 RC 99283 HCPCS both 728 546 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 647.92 89 999999999 567.84 691.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND LOW LEVEL OF MEDICAL DECISION MAKING" 9511005_1 CDM 450 RC 99283 HCPCS both 728 546 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 647.92 89 999999999 567.84 691.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND LOW LEVEL OF MEDICAL DECISION MAKING" 9511005_1 CDM 450 RC 99283 HCPCS both 728 546 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 655.2 90 999999999 567.84 691.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND LOW LEVEL OF MEDICAL DECISION MAKING" 9511005_1 CDM 450 RC 99283 HCPCS both 728 546 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 691.6 95 999999999 567.84 691.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND LOW LEVEL OF MEDICAL DECISION MAKING" 9511005_1 CDM 450 RC 99283 HCPCS both 728 546 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 691.6 95 999999999 567.84 691.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND LOW LEVEL OF MEDICAL DECISION MAKING" 9511005_1 CDM 450 RC 99283 HCPCS both 728 546 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 647.92 89 999999999 567.84 691.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND LOW LEVEL OF MEDICAL DECISION MAKING" 9511005_1 CDM 450 RC 99283 HCPCS both 728 546 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 640.64 88 999999999 567.84 691.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND LOW LEVEL OF MEDICAL DECISION MAKING" 9511005_1 CDM 450 RC 99283 HCPCS both 728 546 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 647.92 89 999999999 567.84 691.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND LOW LEVEL OF MEDICAL DECISION MAKING" 9511005_2 CDM 450 RC 99283 HCPCS both 728 546 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 655.2 90 999999999 567.84 691.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND LOW LEVEL OF MEDICAL DECISION MAKING" 9511005_2 CDM 450 RC 99283 HCPCS both 728 546 AETNA MCR ADV AETNA MCR ADV 567.84 78 999999999 567.84 691.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND LOW LEVEL OF MEDICAL DECISION MAKING" 9511005_2 CDM 450 RC 99283 HCPCS both 728 546 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 637.51 87.57 999999999 567.84 691.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND LOW LEVEL OF MEDICAL DECISION MAKING" 9511005_2 CDM 450 RC 99283 HCPCS both 728 546 COORDINATED CARE MCAID COORDINATED CARE MCAID 619.31 85.07 999999999 567.84 691.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND LOW LEVEL OF MEDICAL DECISION MAKING" 9511005_2 CDM 450 RC 99283 HCPCS both 728 546 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 619.31 85.07 999999999 567.84 691.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND LOW LEVEL OF MEDICAL DECISION MAKING" 9511005_2 CDM 450 RC 99283 HCPCS both 728 546 MOLINA MCAID MOLINA MCAID 607.15 83.4 999999999 567.84 691.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND LOW LEVEL OF MEDICAL DECISION MAKING" 9511005_2 CDM 450 RC 99283 HCPCS both 728 546 MOLINA MCR ADV MOLINA MCR ADV 647.92 89 999999999 567.84 691.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND LOW LEVEL OF MEDICAL DECISION MAKING" 9511005_2 CDM 450 RC 99283 HCPCS both 728 546 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 647.92 89 999999999 567.84 691.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND LOW LEVEL OF MEDICAL DECISION MAKING" 9511005_2 CDM 450 RC 99283 HCPCS both 728 546 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 647.92 89 999999999 567.84 691.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND LOW LEVEL OF MEDICAL DECISION MAKING" 9511005_2 CDM 450 RC 99283 HCPCS both 728 546 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 655.2 90 999999999 567.84 691.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND LOW LEVEL OF MEDICAL DECISION MAKING" 9511005_2 CDM 450 RC 99283 HCPCS both 728 546 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 691.6 95 999999999 567.84 691.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND LOW LEVEL OF MEDICAL DECISION MAKING" 9511005_2 CDM 450 RC 99283 HCPCS both 728 546 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 691.6 95 999999999 567.84 691.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND LOW LEVEL OF MEDICAL DECISION MAKING" 9511005_2 CDM 450 RC 99283 HCPCS both 728 546 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 647.92 89 999999999 567.84 691.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND LOW LEVEL OF MEDICAL DECISION MAKING" 9511005_2 CDM 450 RC 99283 HCPCS both 728 546 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 640.64 88 999999999 567.84 691.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND LOW LEVEL OF MEDICAL DECISION MAKING" 9511005_2 CDM 450 RC 99283 HCPCS both 728 546 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 647.92 89 999999999 567.84 691.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING" 9511006_1 CDM 450 RC 99284 HCPCS both 1308 981 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1177.2 90 999999999 1020.24 1242.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING" 9511006_1 CDM 450 RC 99284 HCPCS both 1308 981 AETNA MCR ADV AETNA MCR ADV 1020.24 78 999999999 1020.24 1242.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING" 9511006_1 CDM 450 RC 99284 HCPCS both 1308 981 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1145.42 87.57 999999999 1020.24 1242.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING" 9511006_1 CDM 450 RC 99284 HCPCS both 1308 981 COORDINATED CARE MCAID COORDINATED CARE MCAID 1112.72 85.07 999999999 1020.24 1242.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING" 9511006_1 CDM 450 RC 99284 HCPCS both 1308 981 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1112.72 85.07 999999999 1020.24 1242.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING" 9511006_1 CDM 450 RC 99284 HCPCS both 1308 981 MOLINA MCAID MOLINA MCAID 1090.87 83.4 999999999 1020.24 1242.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING" 9511006_1 CDM 450 RC 99284 HCPCS both 1308 981 MOLINA MCR ADV MOLINA MCR ADV 1164.12 89 999999999 1020.24 1242.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING" 9511006_1 CDM 450 RC 99284 HCPCS both 1308 981 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1164.12 89 999999999 1020.24 1242.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING" 9511006_1 CDM 450 RC 99284 HCPCS both 1308 981 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1164.12 89 999999999 1020.24 1242.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING" 9511006_1 CDM 450 RC 99284 HCPCS both 1308 981 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1177.2 90 999999999 1020.24 1242.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING" 9511006_1 CDM 450 RC 99284 HCPCS both 1308 981 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1242.6 95 999999999 1020.24 1242.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING" 9511006_1 CDM 450 RC 99284 HCPCS both 1308 981 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1242.6 95 999999999 1020.24 1242.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING" 9511006_1 CDM 450 RC 99284 HCPCS both 1308 981 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1164.12 89 999999999 1020.24 1242.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING" 9511006_1 CDM 450 RC 99284 HCPCS both 1308 981 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1151.04 88 999999999 1020.24 1242.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING" 9511006_1 CDM 450 RC 99284 HCPCS both 1308 981 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1164.12 89 999999999 1020.24 1242.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING" 9511006_2 CDM 450 RC 99284 HCPCS both 1308 981 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1177.2 90 999999999 1020.24 1242.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING" 9511006_2 CDM 450 RC 99284 HCPCS both 1308 981 AETNA MCR ADV AETNA MCR ADV 1020.24 78 999999999 1020.24 1242.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING" 9511006_2 CDM 450 RC 99284 HCPCS both 1308 981 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1145.42 87.57 999999999 1020.24 1242.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING" 9511006_2 CDM 450 RC 99284 HCPCS both 1308 981 COORDINATED CARE MCAID COORDINATED CARE MCAID 1112.72 85.07 999999999 1020.24 1242.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING" 9511006_2 CDM 450 RC 99284 HCPCS both 1308 981 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1112.72 85.07 999999999 1020.24 1242.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING" 9511006_2 CDM 450 RC 99284 HCPCS both 1308 981 MOLINA MCAID MOLINA MCAID 1090.87 83.4 999999999 1020.24 1242.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING" 9511006_2 CDM 450 RC 99284 HCPCS both 1308 981 MOLINA MCR ADV MOLINA MCR ADV 1164.12 89 999999999 1020.24 1242.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING" 9511006_2 CDM 450 RC 99284 HCPCS both 1308 981 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1164.12 89 999999999 1020.24 1242.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING" 9511006_2 CDM 450 RC 99284 HCPCS both 1308 981 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1164.12 89 999999999 1020.24 1242.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING" 9511006_2 CDM 450 RC 99284 HCPCS both 1308 981 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1177.2 90 999999999 1020.24 1242.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING" 9511006_2 CDM 450 RC 99284 HCPCS both 1308 981 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1242.6 95 999999999 1020.24 1242.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING" 9511006_2 CDM 450 RC 99284 HCPCS both 1308 981 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1242.6 95 999999999 1020.24 1242.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING" 9511006_2 CDM 450 RC 99284 HCPCS both 1308 981 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1164.12 89 999999999 1020.24 1242.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING" 9511006_2 CDM 450 RC 99284 HCPCS both 1308 981 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1151.04 88 999999999 1020.24 1242.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING" 9511006_2 CDM 450 RC 99284 HCPCS both 1308 981 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1164.12 89 999999999 1020.24 1242.6 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND HIGH LEVEL OF MEDICAL DECISION MAKING" 9511007_2 CDM 450 RC 99285 HCPCS both 2835 2126.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 2551.5 90 999999999 2211.3 2693.25 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND HIGH LEVEL OF MEDICAL DECISION MAKING" 9511007_2 CDM 450 RC 99285 HCPCS both 2835 2126.25 AETNA MCR ADV AETNA MCR ADV 2211.3 78 999999999 2211.3 2693.25 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND HIGH LEVEL OF MEDICAL DECISION MAKING" 9511007_2 CDM 450 RC 99285 HCPCS both 2835 2126.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 2482.61 87.57 999999999 2211.3 2693.25 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND HIGH LEVEL OF MEDICAL DECISION MAKING" 9511007_2 CDM 450 RC 99285 HCPCS both 2835 2126.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 2411.73 85.07 999999999 2211.3 2693.25 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND HIGH LEVEL OF MEDICAL DECISION MAKING" 9511007_2 CDM 450 RC 99285 HCPCS both 2835 2126.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 2411.73 85.07 999999999 2211.3 2693.25 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND HIGH LEVEL OF MEDICAL DECISION MAKING" 9511007_2 CDM 450 RC 99285 HCPCS both 2835 2126.25 MOLINA MCAID MOLINA MCAID 2364.39 83.4 999999999 2211.3 2693.25 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND HIGH LEVEL OF MEDICAL DECISION MAKING" 9511007_2 CDM 450 RC 99285 HCPCS both 2835 2126.25 MOLINA MCR ADV MOLINA MCR ADV 2523.15 89 999999999 2211.3 2693.25 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND HIGH LEVEL OF MEDICAL DECISION MAKING" 9511007_2 CDM 450 RC 99285 HCPCS both 2835 2126.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 2523.15 89 999999999 2211.3 2693.25 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND HIGH LEVEL OF MEDICAL DECISION MAKING" 9511007_2 CDM 450 RC 99285 HCPCS both 2835 2126.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 2523.15 89 999999999 2211.3 2693.25 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND HIGH LEVEL OF MEDICAL DECISION MAKING" 9511007_2 CDM 450 RC 99285 HCPCS both 2835 2126.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 2551.5 90 999999999 2211.3 2693.25 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND HIGH LEVEL OF MEDICAL DECISION MAKING" 9511007_2 CDM 450 RC 99285 HCPCS both 2835 2126.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 2693.25 95 999999999 2211.3 2693.25 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND HIGH LEVEL OF MEDICAL DECISION MAKING" 9511007_2 CDM 450 RC 99285 HCPCS both 2835 2126.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 2693.25 95 999999999 2211.3 2693.25 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND HIGH LEVEL OF MEDICAL DECISION MAKING" 9511007_2 CDM 450 RC 99285 HCPCS both 2835 2126.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 2523.15 89 999999999 2211.3 2693.25 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND HIGH LEVEL OF MEDICAL DECISION MAKING" 9511007_2 CDM 450 RC 99285 HCPCS both 2835 2126.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 2494.8 88 999999999 2211.3 2693.25 percent of total billed charges "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND HIGH LEVEL OF MEDICAL DECISION MAKING" 9511007_2 CDM 450 RC 99285 HCPCS both 2835 2126.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 2523.15 89 999999999 2211.3 2693.25 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 9511364_1 CDM 761 RC 29130 HCPCS outpatient 138 103.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 124.2 999999999 107.64 131.1 case rate APPLICATION OF FINGER SPLINT; STATIC 9511364_1 CDM 761 RC 29130 HCPCS outpatient 138 103.5 AETNA MCR ADV AETNA MCR ADV 107.64 78 999999999 107.64 131.1 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 9511364_1 CDM 761 RC 29130 HCPCS outpatient 138 103.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 120.85 87.57 999999999 107.64 131.1 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 9511364_1 CDM 761 RC 29130 HCPCS outpatient 138 103.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 117.4 85.07 999999999 107.64 131.1 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 9511364_1 CDM 761 RC 29130 HCPCS outpatient 138 103.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 117.4 85.07 999999999 107.64 131.1 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 9511364_1 CDM 761 RC 29130 HCPCS outpatient 138 103.5 MOLINA MCAID MOLINA MCAID 115.09 83.4 999999999 107.64 131.1 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 9511364_1 CDM 761 RC 29130 HCPCS outpatient 138 103.5 MOLINA MCR ADV MOLINA MCR ADV 122.82 89 999999999 107.64 131.1 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 9511364_1 CDM 761 RC 29130 HCPCS outpatient 138 103.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 122.82 89 999999999 107.64 131.1 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 9511364_1 CDM 761 RC 29130 HCPCS outpatient 138 103.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 122.82 89 999999999 107.64 131.1 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 9511364_1 CDM 761 RC 29130 HCPCS outpatient 138 103.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 124.2 90 999999999 107.64 131.1 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 9511364_1 CDM 761 RC 29130 HCPCS outpatient 138 103.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 131.1 95 999999999 107.64 131.1 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 9511364_1 CDM 761 RC 29130 HCPCS outpatient 138 103.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 131.1 95 999999999 107.64 131.1 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 9511364_1 CDM 761 RC 29130 HCPCS outpatient 138 103.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 122.82 89 999999999 107.64 131.1 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 9511364_1 CDM 761 RC 29130 HCPCS outpatient 138 103.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 121.44 88 999999999 107.64 131.1 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 9511364_1 CDM 761 RC 29130 HCPCS outpatient 138 103.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 122.82 89 999999999 107.64 131.1 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 9511364_2 CDM 761 RC 29130 HCPCS outpatient 138 103.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 124.2 999999999 107.64 131.1 case rate APPLICATION OF FINGER SPLINT; STATIC 9511364_2 CDM 761 RC 29130 HCPCS outpatient 138 103.5 AETNA MCR ADV AETNA MCR ADV 107.64 78 999999999 107.64 131.1 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 9511364_2 CDM 761 RC 29130 HCPCS outpatient 138 103.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 120.85 87.57 999999999 107.64 131.1 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 9511364_2 CDM 761 RC 29130 HCPCS outpatient 138 103.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 117.4 85.07 999999999 107.64 131.1 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 9511364_2 CDM 761 RC 29130 HCPCS outpatient 138 103.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 117.4 85.07 999999999 107.64 131.1 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 9511364_2 CDM 761 RC 29130 HCPCS outpatient 138 103.5 MOLINA MCAID MOLINA MCAID 115.09 83.4 999999999 107.64 131.1 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 9511364_2 CDM 761 RC 29130 HCPCS outpatient 138 103.5 MOLINA MCR ADV MOLINA MCR ADV 122.82 89 999999999 107.64 131.1 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 9511364_2 CDM 761 RC 29130 HCPCS outpatient 138 103.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 122.82 89 999999999 107.64 131.1 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 9511364_2 CDM 761 RC 29130 HCPCS outpatient 138 103.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 122.82 89 999999999 107.64 131.1 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 9511364_2 CDM 761 RC 29130 HCPCS outpatient 138 103.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 124.2 90 999999999 107.64 131.1 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 9511364_2 CDM 761 RC 29130 HCPCS outpatient 138 103.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 131.1 95 999999999 107.64 131.1 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 9511364_2 CDM 761 RC 29130 HCPCS outpatient 138 103.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 131.1 95 999999999 107.64 131.1 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 9511364_2 CDM 761 RC 29130 HCPCS outpatient 138 103.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 122.82 89 999999999 107.64 131.1 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 9511364_2 CDM 761 RC 29130 HCPCS outpatient 138 103.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 121.44 88 999999999 107.64 131.1 percent of total billed charges APPLICATION OF FINGER SPLINT; STATIC 9511364_2 CDM 761 RC 29130 HCPCS outpatient 138 103.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 122.82 89 999999999 107.64 131.1 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 9511368_1 CDM 761 RC 29105 HCPCS outpatient 215 161.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 193.5 999999999 167.7 204.25 case rate APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 9511368_1 CDM 761 RC 29105 HCPCS outpatient 215 161.25 AETNA MCR ADV AETNA MCR ADV 167.7 78 999999999 167.7 204.25 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 9511368_1 CDM 761 RC 29105 HCPCS outpatient 215 161.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 188.28 87.57 999999999 167.7 204.25 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 9511368_1 CDM 761 RC 29105 HCPCS outpatient 215 161.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 182.9 85.07 999999999 167.7 204.25 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 9511368_1 CDM 761 RC 29105 HCPCS outpatient 215 161.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 182.9 85.07 999999999 167.7 204.25 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 9511368_1 CDM 761 RC 29105 HCPCS outpatient 215 161.25 MOLINA MCAID MOLINA MCAID 179.31 83.4 999999999 167.7 204.25 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 9511368_1 CDM 761 RC 29105 HCPCS outpatient 215 161.25 MOLINA MCR ADV MOLINA MCR ADV 191.35 89 999999999 167.7 204.25 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 9511368_1 CDM 761 RC 29105 HCPCS outpatient 215 161.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 191.35 89 999999999 167.7 204.25 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 9511368_1 CDM 761 RC 29105 HCPCS outpatient 215 161.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 191.35 89 999999999 167.7 204.25 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 9511368_1 CDM 761 RC 29105 HCPCS outpatient 215 161.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 193.5 90 999999999 167.7 204.25 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 9511368_1 CDM 761 RC 29105 HCPCS outpatient 215 161.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 204.25 95 999999999 167.7 204.25 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 9511368_1 CDM 761 RC 29105 HCPCS outpatient 215 161.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 204.25 95 999999999 167.7 204.25 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 9511368_1 CDM 761 RC 29105 HCPCS outpatient 215 161.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 191.35 89 999999999 167.7 204.25 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 9511368_1 CDM 761 RC 29105 HCPCS outpatient 215 161.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 189.2 88 999999999 167.7 204.25 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 9511368_1 CDM 761 RC 29105 HCPCS outpatient 215 161.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 191.35 89 999999999 167.7 204.25 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 9511368_2 CDM 761 RC 29105 HCPCS outpatient 215 161.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 193.5 999999999 167.7 204.25 case rate APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 9511368_2 CDM 761 RC 29105 HCPCS outpatient 215 161.25 AETNA MCR ADV AETNA MCR ADV 167.7 78 999999999 167.7 204.25 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 9511368_2 CDM 761 RC 29105 HCPCS outpatient 215 161.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 188.28 87.57 999999999 167.7 204.25 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 9511368_2 CDM 761 RC 29105 HCPCS outpatient 215 161.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 182.9 85.07 999999999 167.7 204.25 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 9511368_2 CDM 761 RC 29105 HCPCS outpatient 215 161.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 182.9 85.07 999999999 167.7 204.25 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 9511368_2 CDM 761 RC 29105 HCPCS outpatient 215 161.25 MOLINA MCAID MOLINA MCAID 179.31 83.4 999999999 167.7 204.25 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 9511368_2 CDM 761 RC 29105 HCPCS outpatient 215 161.25 MOLINA MCR ADV MOLINA MCR ADV 191.35 89 999999999 167.7 204.25 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 9511368_2 CDM 761 RC 29105 HCPCS outpatient 215 161.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 191.35 89 999999999 167.7 204.25 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 9511368_2 CDM 761 RC 29105 HCPCS outpatient 215 161.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 191.35 89 999999999 167.7 204.25 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 9511368_2 CDM 761 RC 29105 HCPCS outpatient 215 161.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 193.5 90 999999999 167.7 204.25 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 9511368_2 CDM 761 RC 29105 HCPCS outpatient 215 161.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 204.25 95 999999999 167.7 204.25 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 9511368_2 CDM 761 RC 29105 HCPCS outpatient 215 161.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 204.25 95 999999999 167.7 204.25 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 9511368_2 CDM 761 RC 29105 HCPCS outpatient 215 161.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 191.35 89 999999999 167.7 204.25 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 9511368_2 CDM 761 RC 29105 HCPCS outpatient 215 161.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 189.2 88 999999999 167.7 204.25 percent of total billed charges APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 9511368_2 CDM 761 RC 29105 HCPCS outpatient 215 161.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 191.35 89 999999999 167.7 204.25 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 9511369_1 CDM 761 RC 29505 HCPCS outpatient 437 327.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 393.3 999999999 340.86 415.15 case rate APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 9511369_1 CDM 761 RC 29505 HCPCS outpatient 437 327.75 AETNA MCR ADV AETNA MCR ADV 340.86 78 999999999 340.86 415.15 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 9511369_1 CDM 761 RC 29505 HCPCS outpatient 437 327.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 382.68 87.57 999999999 340.86 415.15 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 9511369_1 CDM 761 RC 29505 HCPCS outpatient 437 327.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 371.76 85.07 999999999 340.86 415.15 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 9511369_1 CDM 761 RC 29505 HCPCS outpatient 437 327.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 371.76 85.07 999999999 340.86 415.15 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 9511369_1 CDM 761 RC 29505 HCPCS outpatient 437 327.75 MOLINA MCAID MOLINA MCAID 364.46 83.4 999999999 340.86 415.15 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 9511369_1 CDM 761 RC 29505 HCPCS outpatient 437 327.75 MOLINA MCR ADV MOLINA MCR ADV 388.93 89 999999999 340.86 415.15 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 9511369_1 CDM 761 RC 29505 HCPCS outpatient 437 327.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 388.93 89 999999999 340.86 415.15 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 9511369_1 CDM 761 RC 29505 HCPCS outpatient 437 327.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 388.93 89 999999999 340.86 415.15 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 9511369_1 CDM 761 RC 29505 HCPCS outpatient 437 327.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 393.3 90 999999999 340.86 415.15 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 9511369_1 CDM 761 RC 29505 HCPCS outpatient 437 327.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 415.15 95 999999999 340.86 415.15 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 9511369_1 CDM 761 RC 29505 HCPCS outpatient 437 327.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 415.15 95 999999999 340.86 415.15 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 9511369_1 CDM 761 RC 29505 HCPCS outpatient 437 327.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 388.93 89 999999999 340.86 415.15 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 9511369_1 CDM 761 RC 29505 HCPCS outpatient 437 327.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 384.56 88 999999999 340.86 415.15 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 9511369_1 CDM 761 RC 29505 HCPCS outpatient 437 327.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 388.93 89 999999999 340.86 415.15 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 9511369_2 CDM 761 RC 29505 HCPCS outpatient 437 327.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 393.3 999999999 340.86 415.15 case rate APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 9511369_2 CDM 761 RC 29505 HCPCS outpatient 437 327.75 AETNA MCR ADV AETNA MCR ADV 340.86 78 999999999 340.86 415.15 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 9511369_2 CDM 761 RC 29505 HCPCS outpatient 437 327.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 382.68 87.57 999999999 340.86 415.15 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 9511369_2 CDM 761 RC 29505 HCPCS outpatient 437 327.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 371.76 85.07 999999999 340.86 415.15 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 9511369_2 CDM 761 RC 29505 HCPCS outpatient 437 327.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 371.76 85.07 999999999 340.86 415.15 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 9511369_2 CDM 761 RC 29505 HCPCS outpatient 437 327.75 MOLINA MCAID MOLINA MCAID 364.46 83.4 999999999 340.86 415.15 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 9511369_2 CDM 761 RC 29505 HCPCS outpatient 437 327.75 MOLINA MCR ADV MOLINA MCR ADV 388.93 89 999999999 340.86 415.15 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 9511369_2 CDM 761 RC 29505 HCPCS outpatient 437 327.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 388.93 89 999999999 340.86 415.15 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 9511369_2 CDM 761 RC 29505 HCPCS outpatient 437 327.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 388.93 89 999999999 340.86 415.15 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 9511369_2 CDM 761 RC 29505 HCPCS outpatient 437 327.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 393.3 90 999999999 340.86 415.15 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 9511369_2 CDM 761 RC 29505 HCPCS outpatient 437 327.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 415.15 95 999999999 340.86 415.15 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 9511369_2 CDM 761 RC 29505 HCPCS outpatient 437 327.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 415.15 95 999999999 340.86 415.15 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 9511369_2 CDM 761 RC 29505 HCPCS outpatient 437 327.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 388.93 89 999999999 340.86 415.15 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 9511369_2 CDM 761 RC 29505 HCPCS outpatient 437 327.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 384.56 88 999999999 340.86 415.15 percent of total billed charges APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 9511369_2 CDM 761 RC 29505 HCPCS outpatient 437 327.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 388.93 89 999999999 340.86 415.15 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 9511370_1 CDM 761 RC 29125 HCPCS outpatient 179 134.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 161.1 999999999 139.62 170.05 case rate APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 9511370_1 CDM 761 RC 29125 HCPCS outpatient 179 134.25 AETNA MCR ADV AETNA MCR ADV 139.62 78 999999999 139.62 170.05 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 9511370_1 CDM 761 RC 29125 HCPCS outpatient 179 134.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 156.75 87.57 999999999 139.62 170.05 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 9511370_1 CDM 761 RC 29125 HCPCS outpatient 179 134.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 152.28 85.07 999999999 139.62 170.05 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 9511370_1 CDM 761 RC 29125 HCPCS outpatient 179 134.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 152.28 85.07 999999999 139.62 170.05 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 9511370_1 CDM 761 RC 29125 HCPCS outpatient 179 134.25 MOLINA MCAID MOLINA MCAID 149.29 83.4 999999999 139.62 170.05 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 9511370_1 CDM 761 RC 29125 HCPCS outpatient 179 134.25 MOLINA MCR ADV MOLINA MCR ADV 159.31 89 999999999 139.62 170.05 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 9511370_1 CDM 761 RC 29125 HCPCS outpatient 179 134.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 159.31 89 999999999 139.62 170.05 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 9511370_1 CDM 761 RC 29125 HCPCS outpatient 179 134.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 159.31 89 999999999 139.62 170.05 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 9511370_1 CDM 761 RC 29125 HCPCS outpatient 179 134.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 161.1 90 999999999 139.62 170.05 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 9511370_1 CDM 761 RC 29125 HCPCS outpatient 179 134.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 170.05 95 999999999 139.62 170.05 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 9511370_1 CDM 761 RC 29125 HCPCS outpatient 179 134.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 170.05 95 999999999 139.62 170.05 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 9511370_1 CDM 761 RC 29125 HCPCS outpatient 179 134.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 159.31 89 999999999 139.62 170.05 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 9511370_1 CDM 761 RC 29125 HCPCS outpatient 179 134.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 157.52 88 999999999 139.62 170.05 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 9511370_1 CDM 761 RC 29125 HCPCS outpatient 179 134.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 159.31 89 999999999 139.62 170.05 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 9511370_2 CDM 761 RC 29125 HCPCS outpatient 179 134.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 161.1 999999999 139.62 170.05 case rate APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 9511370_2 CDM 761 RC 29125 HCPCS outpatient 179 134.25 AETNA MCR ADV AETNA MCR ADV 139.62 78 999999999 139.62 170.05 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 9511370_2 CDM 761 RC 29125 HCPCS outpatient 179 134.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 156.75 87.57 999999999 139.62 170.05 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 9511370_2 CDM 761 RC 29125 HCPCS outpatient 179 134.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 152.28 85.07 999999999 139.62 170.05 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 9511370_2 CDM 761 RC 29125 HCPCS outpatient 179 134.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 152.28 85.07 999999999 139.62 170.05 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 9511370_2 CDM 761 RC 29125 HCPCS outpatient 179 134.25 MOLINA MCAID MOLINA MCAID 149.29 83.4 999999999 139.62 170.05 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 9511370_2 CDM 761 RC 29125 HCPCS outpatient 179 134.25 MOLINA MCR ADV MOLINA MCR ADV 159.31 89 999999999 139.62 170.05 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 9511370_2 CDM 761 RC 29125 HCPCS outpatient 179 134.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 159.31 89 999999999 139.62 170.05 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 9511370_2 CDM 761 RC 29125 HCPCS outpatient 179 134.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 159.31 89 999999999 139.62 170.05 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 9511370_2 CDM 761 RC 29125 HCPCS outpatient 179 134.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 161.1 90 999999999 139.62 170.05 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 9511370_2 CDM 761 RC 29125 HCPCS outpatient 179 134.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 170.05 95 999999999 139.62 170.05 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 9511370_2 CDM 761 RC 29125 HCPCS outpatient 179 134.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 170.05 95 999999999 139.62 170.05 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 9511370_2 CDM 761 RC 29125 HCPCS outpatient 179 134.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 159.31 89 999999999 139.62 170.05 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 9511370_2 CDM 761 RC 29125 HCPCS outpatient 179 134.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 157.52 88 999999999 139.62 170.05 percent of total billed charges APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 9511370_2 CDM 761 RC 29125 HCPCS outpatient 179 134.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 159.31 89 999999999 139.62 170.05 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 9511373_1 CDM 761 RC 29515 HCPCS outpatient 304 228 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 273.6 999999999 237.12 288.8 case rate APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 9511373_1 CDM 761 RC 29515 HCPCS outpatient 304 228 AETNA MCR ADV AETNA MCR ADV 237.12 78 999999999 237.12 288.8 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 9511373_1 CDM 761 RC 29515 HCPCS outpatient 304 228 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 266.21 87.57 999999999 237.12 288.8 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 9511373_1 CDM 761 RC 29515 HCPCS outpatient 304 228 COORDINATED CARE MCAID COORDINATED CARE MCAID 258.61 85.07 999999999 237.12 288.8 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 9511373_1 CDM 761 RC 29515 HCPCS outpatient 304 228 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 258.61 85.07 999999999 237.12 288.8 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 9511373_1 CDM 761 RC 29515 HCPCS outpatient 304 228 MOLINA MCAID MOLINA MCAID 253.54 83.4 999999999 237.12 288.8 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 9511373_1 CDM 761 RC 29515 HCPCS outpatient 304 228 MOLINA MCR ADV MOLINA MCR ADV 270.56 89 999999999 237.12 288.8 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 9511373_1 CDM 761 RC 29515 HCPCS outpatient 304 228 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 270.56 89 999999999 237.12 288.8 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 9511373_1 CDM 761 RC 29515 HCPCS outpatient 304 228 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 270.56 89 999999999 237.12 288.8 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 9511373_1 CDM 761 RC 29515 HCPCS outpatient 304 228 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 273.6 90 999999999 237.12 288.8 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 9511373_1 CDM 761 RC 29515 HCPCS outpatient 304 228 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 288.8 95 999999999 237.12 288.8 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 9511373_1 CDM 761 RC 29515 HCPCS outpatient 304 228 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 288.8 95 999999999 237.12 288.8 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 9511373_1 CDM 761 RC 29515 HCPCS outpatient 304 228 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 270.56 89 999999999 237.12 288.8 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 9511373_1 CDM 761 RC 29515 HCPCS outpatient 304 228 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 267.52 88 999999999 237.12 288.8 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 9511373_1 CDM 761 RC 29515 HCPCS outpatient 304 228 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 270.56 89 999999999 237.12 288.8 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 9511373_2 CDM 761 RC 29515 HCPCS outpatient 304 228 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 273.6 999999999 237.12 288.8 case rate APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 9511373_2 CDM 761 RC 29515 HCPCS outpatient 304 228 AETNA MCR ADV AETNA MCR ADV 237.12 78 999999999 237.12 288.8 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 9511373_2 CDM 761 RC 29515 HCPCS outpatient 304 228 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 266.21 87.57 999999999 237.12 288.8 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 9511373_2 CDM 761 RC 29515 HCPCS outpatient 304 228 COORDINATED CARE MCAID COORDINATED CARE MCAID 258.61 85.07 999999999 237.12 288.8 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 9511373_2 CDM 761 RC 29515 HCPCS outpatient 304 228 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 258.61 85.07 999999999 237.12 288.8 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 9511373_2 CDM 761 RC 29515 HCPCS outpatient 304 228 MOLINA MCAID MOLINA MCAID 253.54 83.4 999999999 237.12 288.8 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 9511373_2 CDM 761 RC 29515 HCPCS outpatient 304 228 MOLINA MCR ADV MOLINA MCR ADV 270.56 89 999999999 237.12 288.8 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 9511373_2 CDM 761 RC 29515 HCPCS outpatient 304 228 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 270.56 89 999999999 237.12 288.8 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 9511373_2 CDM 761 RC 29515 HCPCS outpatient 304 228 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 270.56 89 999999999 237.12 288.8 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 9511373_2 CDM 761 RC 29515 HCPCS outpatient 304 228 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 273.6 90 999999999 237.12 288.8 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 9511373_2 CDM 761 RC 29515 HCPCS outpatient 304 228 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 288.8 95 999999999 237.12 288.8 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 9511373_2 CDM 761 RC 29515 HCPCS outpatient 304 228 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 288.8 95 999999999 237.12 288.8 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 9511373_2 CDM 761 RC 29515 HCPCS outpatient 304 228 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 270.56 89 999999999 237.12 288.8 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 9511373_2 CDM 761 RC 29515 HCPCS outpatient 304 228 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 267.52 88 999999999 237.12 288.8 percent of total billed charges APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 9511373_2 CDM 761 RC 29515 HCPCS outpatient 304 228 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 270.56 89 999999999 237.12 288.8 percent of total billed charges ALCOHOL (ETHANOL); BREATH 9511405_1 CDM 301 RC 82075 HCPCS outpatient 127 95.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 114.3 90 999999999 99.06 120.65 percent of total billed charges ALCOHOL (ETHANOL); BREATH 9511405_1 CDM 301 RC 82075 HCPCS outpatient 127 95.25 AETNA MCR ADV AETNA MCR ADV 99.06 78 999999999 99.06 120.65 percent of total billed charges ALCOHOL (ETHANOL); BREATH 9511405_1 CDM 301 RC 82075 HCPCS outpatient 127 95.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 111.21 87.57 999999999 99.06 120.65 percent of total billed charges ALCOHOL (ETHANOL); BREATH 9511405_1 CDM 301 RC 82075 HCPCS outpatient 127 95.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 108.04 85.07 999999999 99.06 120.65 percent of total billed charges ALCOHOL (ETHANOL); BREATH 9511405_1 CDM 301 RC 82075 HCPCS outpatient 127 95.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 108.04 85.07 999999999 99.06 120.65 percent of total billed charges ALCOHOL (ETHANOL); BREATH 9511405_1 CDM 301 RC 82075 HCPCS outpatient 127 95.25 MOLINA MCAID MOLINA MCAID 105.92 83.4 999999999 99.06 120.65 percent of total billed charges ALCOHOL (ETHANOL); BREATH 9511405_1 CDM 301 RC 82075 HCPCS outpatient 127 95.25 MOLINA MCR ADV MOLINA MCR ADV 113.03 89 999999999 99.06 120.65 percent of total billed charges ALCOHOL (ETHANOL); BREATH 9511405_1 CDM 301 RC 82075 HCPCS outpatient 127 95.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 113.03 89 999999999 99.06 120.65 percent of total billed charges ALCOHOL (ETHANOL); BREATH 9511405_1 CDM 301 RC 82075 HCPCS outpatient 127 95.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 113.03 89 999999999 99.06 120.65 percent of total billed charges ALCOHOL (ETHANOL); BREATH 9511405_1 CDM 301 RC 82075 HCPCS outpatient 127 95.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 114.3 90 999999999 99.06 120.65 percent of total billed charges ALCOHOL (ETHANOL); BREATH 9511405_1 CDM 301 RC 82075 HCPCS outpatient 127 95.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 120.65 95 999999999 99.06 120.65 percent of total billed charges ALCOHOL (ETHANOL); BREATH 9511405_1 CDM 301 RC 82075 HCPCS outpatient 127 95.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 120.65 95 999999999 99.06 120.65 percent of total billed charges ALCOHOL (ETHANOL); BREATH 9511405_1 CDM 301 RC 82075 HCPCS outpatient 127 95.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 113.03 89 999999999 99.06 120.65 percent of total billed charges ALCOHOL (ETHANOL); BREATH 9511405_1 CDM 301 RC 82075 HCPCS outpatient 127 95.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 111.76 88 999999999 99.06 120.65 percent of total billed charges ALCOHOL (ETHANOL); BREATH 9511405_1 CDM 301 RC 82075 HCPCS outpatient 127 95.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 113.03 89 999999999 99.06 120.65 percent of total billed charges PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDING PROVISION OF ALLERGENIC EXTRACTS; SINGLE INJECTION 95115_3 CDM 510 RC 95115 HCPCS outpatient 20 15 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 18 90 999999999 15.6 19 percent of total billed charges PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDING PROVISION OF ALLERGENIC EXTRACTS; SINGLE INJECTION 95115_3 CDM 510 RC 95115 HCPCS outpatient 20 15 AETNA MCR ADV AETNA MCR ADV 15.6 78 999999999 15.6 19 percent of total billed charges PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDING PROVISION OF ALLERGENIC EXTRACTS; SINGLE INJECTION 95115_3 CDM 510 RC 95115 HCPCS outpatient 20 15 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 17.51 87.57 999999999 15.6 19 percent of total billed charges PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDING PROVISION OF ALLERGENIC EXTRACTS; SINGLE INJECTION 95115_3 CDM 510 RC 95115 HCPCS outpatient 20 15 COORDINATED CARE MCAID COORDINATED CARE MCAID 17.01 85.07 999999999 15.6 19 percent of total billed charges PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDING PROVISION OF ALLERGENIC EXTRACTS; SINGLE INJECTION 95115_3 CDM 510 RC 95115 HCPCS outpatient 20 15 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 17.01 85.07 999999999 15.6 19 percent of total billed charges PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDING PROVISION OF ALLERGENIC EXTRACTS; SINGLE INJECTION 95115_3 CDM 510 RC 95115 HCPCS outpatient 20 15 MOLINA MCAID MOLINA MCAID 16.68 83.4 999999999 15.6 19 percent of total billed charges PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDING PROVISION OF ALLERGENIC EXTRACTS; SINGLE INJECTION 95115_3 CDM 510 RC 95115 HCPCS outpatient 20 15 MOLINA MCR ADV MOLINA MCR ADV 17.8 89 999999999 15.6 19 percent of total billed charges PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDING PROVISION OF ALLERGENIC EXTRACTS; SINGLE INJECTION 95115_3 CDM 510 RC 95115 HCPCS outpatient 20 15 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 17.8 89 999999999 15.6 19 percent of total billed charges PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDING PROVISION OF ALLERGENIC EXTRACTS; SINGLE INJECTION 95115_3 CDM 510 RC 95115 HCPCS outpatient 20 15 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 17.8 89 999999999 15.6 19 percent of total billed charges PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDING PROVISION OF ALLERGENIC EXTRACTS; SINGLE INJECTION 95115_3 CDM 510 RC 95115 HCPCS outpatient 20 15 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 18 90 999999999 15.6 19 percent of total billed charges PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDING PROVISION OF ALLERGENIC EXTRACTS; SINGLE INJECTION 95115_3 CDM 510 RC 95115 HCPCS outpatient 20 15 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 999999999 15.6 19 other Non-Covered [Rev Code] ( 1*0 ) Term Line 43 PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDING PROVISION OF ALLERGENIC EXTRACTS; SINGLE INJECTION 95115_3 CDM 510 RC 95115 HCPCS outpatient 20 15 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 19 95 999999999 15.6 19 percent of total billed charges PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDING PROVISION OF ALLERGENIC EXTRACTS; SINGLE INJECTION 95115_3 CDM 510 RC 95115 HCPCS outpatient 20 15 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 17.8 89 999999999 15.6 19 percent of total billed charges PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDING PROVISION OF ALLERGENIC EXTRACTS; SINGLE INJECTION 95115_3 CDM 510 RC 95115 HCPCS outpatient 20 15 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 17.6 88 999999999 15.6 19 percent of total billed charges PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDING PROVISION OF ALLERGENIC EXTRACTS; SINGLE INJECTION 95115_3 CDM 510 RC 95115 HCPCS outpatient 20 15 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 17.8 89 999999999 15.6 19 percent of total billed charges PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDING PROVISION OF ALLERGENIC EXTRACTS; 2 OR MORE INJECTIONS 95117_3 CDM 510 RC 95117 HCPCS outpatient 23 17.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 20.7 90 999999999 17.94 21.85 percent of total billed charges PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDING PROVISION OF ALLERGENIC EXTRACTS; 2 OR MORE INJECTIONS 95117_3 CDM 510 RC 95117 HCPCS outpatient 23 17.25 AETNA MCR ADV AETNA MCR ADV 17.94 78 999999999 17.94 21.85 percent of total billed charges PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDING PROVISION OF ALLERGENIC EXTRACTS; 2 OR MORE INJECTIONS 95117_3 CDM 510 RC 95117 HCPCS outpatient 23 17.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 20.14 87.57 999999999 17.94 21.85 percent of total billed charges PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDING PROVISION OF ALLERGENIC EXTRACTS; 2 OR MORE INJECTIONS 95117_3 CDM 510 RC 95117 HCPCS outpatient 23 17.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 19.57 85.07 999999999 17.94 21.85 percent of total billed charges PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDING PROVISION OF ALLERGENIC EXTRACTS; 2 OR MORE INJECTIONS 95117_3 CDM 510 RC 95117 HCPCS outpatient 23 17.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 19.57 85.07 999999999 17.94 21.85 percent of total billed charges PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDING PROVISION OF ALLERGENIC EXTRACTS; 2 OR MORE INJECTIONS 95117_3 CDM 510 RC 95117 HCPCS outpatient 23 17.25 MOLINA MCAID MOLINA MCAID 19.18 83.4 999999999 17.94 21.85 percent of total billed charges PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDING PROVISION OF ALLERGENIC EXTRACTS; 2 OR MORE INJECTIONS 95117_3 CDM 510 RC 95117 HCPCS outpatient 23 17.25 MOLINA MCR ADV MOLINA MCR ADV 20.47 89 999999999 17.94 21.85 percent of total billed charges PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDING PROVISION OF ALLERGENIC EXTRACTS; 2 OR MORE INJECTIONS 95117_3 CDM 510 RC 95117 HCPCS outpatient 23 17.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 20.47 89 999999999 17.94 21.85 percent of total billed charges PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDING PROVISION OF ALLERGENIC EXTRACTS; 2 OR MORE INJECTIONS 95117_3 CDM 510 RC 95117 HCPCS outpatient 23 17.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 20.47 89 999999999 17.94 21.85 percent of total billed charges PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDING PROVISION OF ALLERGENIC EXTRACTS; 2 OR MORE INJECTIONS 95117_3 CDM 510 RC 95117 HCPCS outpatient 23 17.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 20.7 90 999999999 17.94 21.85 percent of total billed charges PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDING PROVISION OF ALLERGENIC EXTRACTS; 2 OR MORE INJECTIONS 95117_3 CDM 510 RC 95117 HCPCS outpatient 23 17.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 999999999 17.94 21.85 other Non-Covered [Rev Code] ( 1*0 ) Term Line 43 PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDING PROVISION OF ALLERGENIC EXTRACTS; 2 OR MORE INJECTIONS 95117_3 CDM 510 RC 95117 HCPCS outpatient 23 17.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 21.85 95 999999999 17.94 21.85 percent of total billed charges PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDING PROVISION OF ALLERGENIC EXTRACTS; 2 OR MORE INJECTIONS 95117_3 CDM 510 RC 95117 HCPCS outpatient 23 17.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 20.47 89 999999999 17.94 21.85 percent of total billed charges PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDING PROVISION OF ALLERGENIC EXTRACTS; 2 OR MORE INJECTIONS 95117_3 CDM 510 RC 95117 HCPCS outpatient 23 17.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 20.24 88 999999999 17.94 21.85 percent of total billed charges PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDING PROVISION OF ALLERGENIC EXTRACTS; 2 OR MORE INJECTIONS 95117_3 CDM 510 RC 95117 HCPCS outpatient 23 17.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 20.47 89 999999999 17.94 21.85 percent of total billed charges STRAPPING; ANKLE AND/OR FOOT 9512144_1 CDM 761 RC 29540 HCPCS outpatient 179 134.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 161.1 999999999 139.62 170.05 case rate STRAPPING; ANKLE AND/OR FOOT 9512144_1 CDM 761 RC 29540 HCPCS outpatient 179 134.25 AETNA MCR ADV AETNA MCR ADV 139.62 78 999999999 139.62 170.05 percent of total billed charges STRAPPING; ANKLE AND/OR FOOT 9512144_1 CDM 761 RC 29540 HCPCS outpatient 179 134.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 156.75 87.57 999999999 139.62 170.05 percent of total billed charges STRAPPING; ANKLE AND/OR FOOT 9512144_1 CDM 761 RC 29540 HCPCS outpatient 179 134.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 152.28 85.07 999999999 139.62 170.05 percent of total billed charges STRAPPING; ANKLE AND/OR FOOT 9512144_1 CDM 761 RC 29540 HCPCS outpatient 179 134.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 152.28 85.07 999999999 139.62 170.05 percent of total billed charges STRAPPING; ANKLE AND/OR FOOT 9512144_1 CDM 761 RC 29540 HCPCS outpatient 179 134.25 MOLINA MCAID MOLINA MCAID 149.29 83.4 999999999 139.62 170.05 percent of total billed charges STRAPPING; ANKLE AND/OR FOOT 9512144_1 CDM 761 RC 29540 HCPCS outpatient 179 134.25 MOLINA MCR ADV MOLINA MCR ADV 159.31 89 999999999 139.62 170.05 percent of total billed charges STRAPPING; ANKLE AND/OR FOOT 9512144_1 CDM 761 RC 29540 HCPCS outpatient 179 134.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 159.31 89 999999999 139.62 170.05 percent of total billed charges STRAPPING; ANKLE AND/OR FOOT 9512144_1 CDM 761 RC 29540 HCPCS outpatient 179 134.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 159.31 89 999999999 139.62 170.05 percent of total billed charges STRAPPING; ANKLE AND/OR FOOT 9512144_1 CDM 761 RC 29540 HCPCS outpatient 179 134.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 161.1 90 999999999 139.62 170.05 percent of total billed charges STRAPPING; ANKLE AND/OR FOOT 9512144_1 CDM 761 RC 29540 HCPCS outpatient 179 134.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 170.05 95 999999999 139.62 170.05 percent of total billed charges STRAPPING; ANKLE AND/OR FOOT 9512144_1 CDM 761 RC 29540 HCPCS outpatient 179 134.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 170.05 95 999999999 139.62 170.05 percent of total billed charges STRAPPING; ANKLE AND/OR FOOT 9512144_1 CDM 761 RC 29540 HCPCS outpatient 179 134.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 159.31 89 999999999 139.62 170.05 percent of total billed charges STRAPPING; ANKLE AND/OR FOOT 9512144_1 CDM 761 RC 29540 HCPCS outpatient 179 134.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 157.52 88 999999999 139.62 170.05 percent of total billed charges STRAPPING; ANKLE AND/OR FOOT 9512144_1 CDM 761 RC 29540 HCPCS outpatient 179 134.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 159.31 89 999999999 139.62 170.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE" 9512286_1 CDM 490 RC 64418 HCPCS outpatient 1247 935.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1122.3 999999999 972.66 1184.65 case rate "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE" 9512286_1 CDM 490 RC 64418 HCPCS outpatient 1247 935.25 AETNA MCR ADV AETNA MCR ADV 972.66 78 999999999 972.66 1184.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE" 9512286_1 CDM 490 RC 64418 HCPCS outpatient 1247 935.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1092 87.57 999999999 972.66 1184.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE" 9512286_1 CDM 490 RC 64418 HCPCS outpatient 1247 935.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 1060.82 85.07 999999999 972.66 1184.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE" 9512286_1 CDM 490 RC 64418 HCPCS outpatient 1247 935.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1060.82 85.07 999999999 972.66 1184.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE" 9512286_1 CDM 490 RC 64418 HCPCS outpatient 1247 935.25 MOLINA MCAID MOLINA MCAID 1040 83.4 999999999 972.66 1184.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE" 9512286_1 CDM 490 RC 64418 HCPCS outpatient 1247 935.25 MOLINA MCR ADV MOLINA MCR ADV 1109.83 89 999999999 972.66 1184.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE" 9512286_1 CDM 490 RC 64418 HCPCS outpatient 1247 935.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1109.83 89 999999999 972.66 1184.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE" 9512286_1 CDM 490 RC 64418 HCPCS outpatient 1247 935.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1109.83 89 999999999 972.66 1184.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE" 9512286_1 CDM 490 RC 64418 HCPCS outpatient 1247 935.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1122.3 90 999999999 972.66 1184.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE" 9512286_1 CDM 490 RC 64418 HCPCS outpatient 1247 935.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1184.65 95 999999999 972.66 1184.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE" 9512286_1 CDM 490 RC 64418 HCPCS outpatient 1247 935.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1184.65 95 999999999 972.66 1184.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE" 9512286_1 CDM 490 RC 64418 HCPCS outpatient 1247 935.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1109.83 89 999999999 972.66 1184.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE" 9512286_1 CDM 490 RC 64418 HCPCS outpatient 1247 935.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1097.36 88 999999999 972.66 1184.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE" 9512286_1 CDM 490 RC 64418 HCPCS outpatient 1247 935.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1109.83 89 999999999 972.66 1184.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9512295_1 CDM 490 RC 64445 HCPCS outpatient 1247 935.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1122.3 999999999 972.66 1184.65 case rate "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9512295_1 CDM 490 RC 64445 HCPCS outpatient 1247 935.25 AETNA MCR ADV AETNA MCR ADV 972.66 78 999999999 972.66 1184.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9512295_1 CDM 490 RC 64445 HCPCS outpatient 1247 935.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1092 87.57 999999999 972.66 1184.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9512295_1 CDM 490 RC 64445 HCPCS outpatient 1247 935.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 1060.82 85.07 999999999 972.66 1184.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9512295_1 CDM 490 RC 64445 HCPCS outpatient 1247 935.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1060.82 85.07 999999999 972.66 1184.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9512295_1 CDM 490 RC 64445 HCPCS outpatient 1247 935.25 MOLINA MCAID MOLINA MCAID 1040 83.4 999999999 972.66 1184.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9512295_1 CDM 490 RC 64445 HCPCS outpatient 1247 935.25 MOLINA MCR ADV MOLINA MCR ADV 1109.83 89 999999999 972.66 1184.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9512295_1 CDM 490 RC 64445 HCPCS outpatient 1247 935.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1109.83 89 999999999 972.66 1184.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9512295_1 CDM 490 RC 64445 HCPCS outpatient 1247 935.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1109.83 89 999999999 972.66 1184.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9512295_1 CDM 490 RC 64445 HCPCS outpatient 1247 935.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1122.3 90 999999999 972.66 1184.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9512295_1 CDM 490 RC 64445 HCPCS outpatient 1247 935.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1184.65 95 999999999 972.66 1184.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9512295_1 CDM 490 RC 64445 HCPCS outpatient 1247 935.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1184.65 95 999999999 972.66 1184.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9512295_1 CDM 490 RC 64445 HCPCS outpatient 1247 935.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1109.83 89 999999999 972.66 1184.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9512295_1 CDM 490 RC 64445 HCPCS outpatient 1247 935.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1097.36 88 999999999 972.66 1184.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9512295_1 CDM 490 RC 64445 HCPCS outpatient 1247 935.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1109.83 89 999999999 972.66 1184.65 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9512295_50_1 CDM 490 RC 64445 HCPCS outpatient 1870 1402.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 1683 999999999 1458.6 1776.5 case rate "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9512295_50_1 CDM 490 RC 64445 HCPCS outpatient 1870 1402.5 AETNA MCR ADV AETNA MCR ADV 50 1458.6 78 999999999 1458.6 1776.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9512295_50_1 CDM 490 RC 64445 HCPCS outpatient 1870 1402.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 1637.56 87.57 999999999 1458.6 1776.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9512295_50_1 CDM 490 RC 64445 HCPCS outpatient 1870 1402.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 1590.81 85.07 999999999 1458.6 1776.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9512295_50_1 CDM 490 RC 64445 HCPCS outpatient 1870 1402.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 1590.81 85.07 999999999 1458.6 1776.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9512295_50_1 CDM 490 RC 64445 HCPCS outpatient 1870 1402.5 MOLINA MCAID MOLINA MCAID 50 1559.58 83.4 999999999 1458.6 1776.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9512295_50_1 CDM 490 RC 64445 HCPCS outpatient 1870 1402.5 MOLINA MCR ADV MOLINA MCR ADV 50 1664.3 89 999999999 1458.6 1776.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9512295_50_1 CDM 490 RC 64445 HCPCS outpatient 1870 1402.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 1664.3 89 999999999 1458.6 1776.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9512295_50_1 CDM 490 RC 64445 HCPCS outpatient 1870 1402.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 1664.3 89 999999999 1458.6 1776.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9512295_50_1 CDM 490 RC 64445 HCPCS outpatient 1870 1402.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 1683 90 999999999 1458.6 1776.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9512295_50_1 CDM 490 RC 64445 HCPCS outpatient 1870 1402.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 1776.5 95 999999999 1458.6 1776.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9512295_50_1 CDM 490 RC 64445 HCPCS outpatient 1870 1402.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 1776.5 95 999999999 1458.6 1776.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9512295_50_1 CDM 490 RC 64445 HCPCS outpatient 1870 1402.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 1664.3 89 999999999 1458.6 1776.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9512295_50_1 CDM 490 RC 64445 HCPCS outpatient 1870 1402.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 1645.6 88 999999999 1458.6 1776.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9512295_50_1 CDM 490 RC 64445 HCPCS outpatient 1870 1402.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 1664.3 89 999999999 1458.6 1776.5 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9512507_1 CDM 450 RC 51701 HCPCS both 200 150 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 180 999999999 156 190 case rate "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9512507_1 CDM 450 RC 51701 HCPCS both 200 150 AETNA MCR ADV AETNA MCR ADV 156 78 999999999 156 190 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9512507_1 CDM 450 RC 51701 HCPCS both 200 150 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 175.14 87.57 999999999 156 190 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9512507_1 CDM 450 RC 51701 HCPCS both 200 150 COORDINATED CARE MCAID COORDINATED CARE MCAID 170.14 85.07 999999999 156 190 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9512507_1 CDM 450 RC 51701 HCPCS both 200 150 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 170.14 85.07 999999999 156 190 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9512507_1 CDM 450 RC 51701 HCPCS both 200 150 MOLINA MCAID MOLINA MCAID 166.8 83.4 999999999 156 190 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9512507_1 CDM 450 RC 51701 HCPCS both 200 150 MOLINA MCR ADV MOLINA MCR ADV 178 89 999999999 156 190 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9512507_1 CDM 450 RC 51701 HCPCS both 200 150 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 178 89 999999999 156 190 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9512507_1 CDM 450 RC 51701 HCPCS both 200 150 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 178 89 999999999 156 190 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9512507_1 CDM 450 RC 51701 HCPCS both 200 150 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 180 90 999999999 156 190 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9512507_1 CDM 450 RC 51701 HCPCS both 200 150 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 190 95 999999999 156 190 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9512507_1 CDM 450 RC 51701 HCPCS both 200 150 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 190 95 999999999 156 190 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9512507_1 CDM 450 RC 51701 HCPCS both 200 150 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 178 89 999999999 156 190 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9512507_1 CDM 450 RC 51701 HCPCS both 200 150 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 176 88 999999999 156 190 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9512507_1 CDM 450 RC 51701 HCPCS both 200 150 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 178 89 999999999 156 190 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9512507_2 CDM 450 RC 51701 HCPCS both 200 150 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 180 999999999 156 190 case rate "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9512507_2 CDM 450 RC 51701 HCPCS both 200 150 AETNA MCR ADV AETNA MCR ADV 156 78 999999999 156 190 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9512507_2 CDM 450 RC 51701 HCPCS both 200 150 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 175.14 87.57 999999999 156 190 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9512507_2 CDM 450 RC 51701 HCPCS both 200 150 COORDINATED CARE MCAID COORDINATED CARE MCAID 170.14 85.07 999999999 156 190 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9512507_2 CDM 450 RC 51701 HCPCS both 200 150 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 170.14 85.07 999999999 156 190 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9512507_2 CDM 450 RC 51701 HCPCS both 200 150 MOLINA MCAID MOLINA MCAID 166.8 83.4 999999999 156 190 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9512507_2 CDM 450 RC 51701 HCPCS both 200 150 MOLINA MCR ADV MOLINA MCR ADV 178 89 999999999 156 190 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9512507_2 CDM 450 RC 51701 HCPCS both 200 150 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 178 89 999999999 156 190 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9512507_2 CDM 450 RC 51701 HCPCS both 200 150 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 178 89 999999999 156 190 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9512507_2 CDM 450 RC 51701 HCPCS both 200 150 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 180 90 999999999 156 190 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9512507_2 CDM 450 RC 51701 HCPCS both 200 150 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 190 95 999999999 156 190 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9512507_2 CDM 450 RC 51701 HCPCS both 200 150 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 190 95 999999999 156 190 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9512507_2 CDM 450 RC 51701 HCPCS both 200 150 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 178 89 999999999 156 190 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9512507_2 CDM 450 RC 51701 HCPCS both 200 150 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 176 88 999999999 156 190 percent of total billed charges "INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)" 9512507_2 CDM 450 RC 51701 HCPCS both 200 150 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 178 89 999999999 156 190 percent of total billed charges "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 9512583_1 CDM 361 RC 30300 HCPCS outpatient 150 112.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 135 999999999 117 142.5 case rate "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 9512583_1 CDM 361 RC 30300 HCPCS outpatient 150 112.5 AETNA MCR ADV AETNA MCR ADV 117 78 999999999 117 142.5 percent of total billed charges "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 9512583_1 CDM 361 RC 30300 HCPCS outpatient 150 112.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 131.36 87.57 999999999 117 142.5 percent of total billed charges "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 9512583_1 CDM 361 RC 30300 HCPCS outpatient 150 112.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 127.61 85.07 999999999 117 142.5 percent of total billed charges "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 9512583_1 CDM 361 RC 30300 HCPCS outpatient 150 112.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 127.61 85.07 999999999 117 142.5 percent of total billed charges "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 9512583_1 CDM 361 RC 30300 HCPCS outpatient 150 112.5 MOLINA MCAID MOLINA MCAID 125.1 83.4 999999999 117 142.5 percent of total billed charges "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 9512583_1 CDM 361 RC 30300 HCPCS outpatient 150 112.5 MOLINA MCR ADV MOLINA MCR ADV 133.5 89 999999999 117 142.5 percent of total billed charges "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 9512583_1 CDM 361 RC 30300 HCPCS outpatient 150 112.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 133.5 89 999999999 117 142.5 percent of total billed charges "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 9512583_1 CDM 361 RC 30300 HCPCS outpatient 150 112.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 133.5 89 999999999 117 142.5 percent of total billed charges "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 9512583_1 CDM 361 RC 30300 HCPCS outpatient 150 112.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 135 90 999999999 117 142.5 percent of total billed charges "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 9512583_1 CDM 361 RC 30300 HCPCS outpatient 150 112.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 142.5 95 999999999 117 142.5 percent of total billed charges "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 9512583_1 CDM 361 RC 30300 HCPCS outpatient 150 112.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 142.5 95 999999999 117 142.5 percent of total billed charges "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 9512583_1 CDM 361 RC 30300 HCPCS outpatient 150 112.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 133.5 89 999999999 117 142.5 percent of total billed charges "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 9512583_1 CDM 361 RC 30300 HCPCS outpatient 150 112.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 132 88 999999999 117 142.5 percent of total billed charges "REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE" 9512583_1 CDM 361 RC 30300 HCPCS outpatient 150 112.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 133.5 89 999999999 117 142.5 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 9512584_1 CDM 361 RC 30901 HCPCS outpatient 365 273.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 328.5 999999999 284.7 346.75 case rate "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 9512584_1 CDM 361 RC 30901 HCPCS outpatient 365 273.75 AETNA MCR ADV AETNA MCR ADV 284.7 78 999999999 284.7 346.75 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 9512584_1 CDM 361 RC 30901 HCPCS outpatient 365 273.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 319.63 87.57 999999999 284.7 346.75 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 9512584_1 CDM 361 RC 30901 HCPCS outpatient 365 273.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 310.51 85.07 999999999 284.7 346.75 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 9512584_1 CDM 361 RC 30901 HCPCS outpatient 365 273.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 310.51 85.07 999999999 284.7 346.75 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 9512584_1 CDM 361 RC 30901 HCPCS outpatient 365 273.75 MOLINA MCAID MOLINA MCAID 304.41 83.4 999999999 284.7 346.75 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 9512584_1 CDM 361 RC 30901 HCPCS outpatient 365 273.75 MOLINA MCR ADV MOLINA MCR ADV 324.85 89 999999999 284.7 346.75 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 9512584_1 CDM 361 RC 30901 HCPCS outpatient 365 273.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 324.85 89 999999999 284.7 346.75 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 9512584_1 CDM 361 RC 30901 HCPCS outpatient 365 273.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 324.85 89 999999999 284.7 346.75 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 9512584_1 CDM 361 RC 30901 HCPCS outpatient 365 273.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 328.5 90 999999999 284.7 346.75 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 9512584_1 CDM 361 RC 30901 HCPCS outpatient 365 273.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 346.75 95 999999999 284.7 346.75 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 9512584_1 CDM 361 RC 30901 HCPCS outpatient 365 273.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 346.75 95 999999999 284.7 346.75 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 9512584_1 CDM 361 RC 30901 HCPCS outpatient 365 273.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 324.85 89 999999999 284.7 346.75 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 9512584_1 CDM 361 RC 30901 HCPCS outpatient 365 273.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 321.2 88 999999999 284.7 346.75 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 9512584_1 CDM 361 RC 30901 HCPCS outpatient 365 273.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 324.85 89 999999999 284.7 346.75 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 9512584_2 CDM 361 RC 30901 HCPCS outpatient 365 273.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 328.5 999999999 284.7 346.75 case rate "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 9512584_2 CDM 361 RC 30901 HCPCS outpatient 365 273.75 AETNA MCR ADV AETNA MCR ADV 284.7 78 999999999 284.7 346.75 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 9512584_2 CDM 361 RC 30901 HCPCS outpatient 365 273.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 319.63 87.57 999999999 284.7 346.75 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 9512584_2 CDM 361 RC 30901 HCPCS outpatient 365 273.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 310.51 85.07 999999999 284.7 346.75 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 9512584_2 CDM 361 RC 30901 HCPCS outpatient 365 273.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 310.51 85.07 999999999 284.7 346.75 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 9512584_2 CDM 361 RC 30901 HCPCS outpatient 365 273.75 MOLINA MCAID MOLINA MCAID 304.41 83.4 999999999 284.7 346.75 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 9512584_2 CDM 361 RC 30901 HCPCS outpatient 365 273.75 MOLINA MCR ADV MOLINA MCR ADV 324.85 89 999999999 284.7 346.75 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 9512584_2 CDM 361 RC 30901 HCPCS outpatient 365 273.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 324.85 89 999999999 284.7 346.75 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 9512584_2 CDM 361 RC 30901 HCPCS outpatient 365 273.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 324.85 89 999999999 284.7 346.75 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 9512584_2 CDM 361 RC 30901 HCPCS outpatient 365 273.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 328.5 90 999999999 284.7 346.75 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 9512584_2 CDM 361 RC 30901 HCPCS outpatient 365 273.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 346.75 95 999999999 284.7 346.75 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 9512584_2 CDM 361 RC 30901 HCPCS outpatient 365 273.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 346.75 95 999999999 284.7 346.75 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 9512584_2 CDM 361 RC 30901 HCPCS outpatient 365 273.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 324.85 89 999999999 284.7 346.75 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 9512584_2 CDM 361 RC 30901 HCPCS outpatient 365 273.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 321.2 88 999999999 284.7 346.75 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD" 9512584_2 CDM 361 RC 30901 HCPCS outpatient 365 273.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 324.85 89 999999999 284.7 346.75 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 9512596_1 CDM 361 RC 69200 HCPCS outpatient 281 210.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 252.9 999999999 219.18 266.95 case rate REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 9512596_1 CDM 361 RC 69200 HCPCS outpatient 281 210.75 AETNA MCR ADV AETNA MCR ADV 219.18 78 999999999 219.18 266.95 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 9512596_1 CDM 361 RC 69200 HCPCS outpatient 281 210.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 246.07 87.57 999999999 219.18 266.95 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 9512596_1 CDM 361 RC 69200 HCPCS outpatient 281 210.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 239.05 85.07 999999999 219.18 266.95 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 9512596_1 CDM 361 RC 69200 HCPCS outpatient 281 210.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 239.05 85.07 999999999 219.18 266.95 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 9512596_1 CDM 361 RC 69200 HCPCS outpatient 281 210.75 MOLINA MCAID MOLINA MCAID 234.35 83.4 999999999 219.18 266.95 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 9512596_1 CDM 361 RC 69200 HCPCS outpatient 281 210.75 MOLINA MCR ADV MOLINA MCR ADV 250.09 89 999999999 219.18 266.95 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 9512596_1 CDM 361 RC 69200 HCPCS outpatient 281 210.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 250.09 89 999999999 219.18 266.95 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 9512596_1 CDM 361 RC 69200 HCPCS outpatient 281 210.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 250.09 89 999999999 219.18 266.95 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 9512596_1 CDM 361 RC 69200 HCPCS outpatient 281 210.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 252.9 90 999999999 219.18 266.95 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 9512596_1 CDM 361 RC 69200 HCPCS outpatient 281 210.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 266.95 95 999999999 219.18 266.95 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 9512596_1 CDM 361 RC 69200 HCPCS outpatient 281 210.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 266.95 95 999999999 219.18 266.95 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 9512596_1 CDM 361 RC 69200 HCPCS outpatient 281 210.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 250.09 89 999999999 219.18 266.95 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 9512596_1 CDM 361 RC 69200 HCPCS outpatient 281 210.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 247.28 88 999999999 219.18 266.95 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 9512596_1 CDM 361 RC 69200 HCPCS outpatient 281 210.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 250.09 89 999999999 219.18 266.95 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 9512596_2 CDM 361 RC 69200 HCPCS outpatient 281 210.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 252.9 999999999 219.18 266.95 case rate REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 9512596_2 CDM 361 RC 69200 HCPCS outpatient 281 210.75 AETNA MCR ADV AETNA MCR ADV 219.18 78 999999999 219.18 266.95 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 9512596_2 CDM 361 RC 69200 HCPCS outpatient 281 210.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 246.07 87.57 999999999 219.18 266.95 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 9512596_2 CDM 361 RC 69200 HCPCS outpatient 281 210.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 239.05 85.07 999999999 219.18 266.95 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 9512596_2 CDM 361 RC 69200 HCPCS outpatient 281 210.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 239.05 85.07 999999999 219.18 266.95 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 9512596_2 CDM 361 RC 69200 HCPCS outpatient 281 210.75 MOLINA MCAID MOLINA MCAID 234.35 83.4 999999999 219.18 266.95 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 9512596_2 CDM 361 RC 69200 HCPCS outpatient 281 210.75 MOLINA MCR ADV MOLINA MCR ADV 250.09 89 999999999 219.18 266.95 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 9512596_2 CDM 361 RC 69200 HCPCS outpatient 281 210.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 250.09 89 999999999 219.18 266.95 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 9512596_2 CDM 361 RC 69200 HCPCS outpatient 281 210.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 250.09 89 999999999 219.18 266.95 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 9512596_2 CDM 361 RC 69200 HCPCS outpatient 281 210.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 252.9 90 999999999 219.18 266.95 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 9512596_2 CDM 361 RC 69200 HCPCS outpatient 281 210.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 266.95 95 999999999 219.18 266.95 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 9512596_2 CDM 361 RC 69200 HCPCS outpatient 281 210.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 266.95 95 999999999 219.18 266.95 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 9512596_2 CDM 361 RC 69200 HCPCS outpatient 281 210.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 250.09 89 999999999 219.18 266.95 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 9512596_2 CDM 361 RC 69200 HCPCS outpatient 281 210.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 247.28 88 999999999 219.18 266.95 percent of total billed charges REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA 9512596_2 CDM 361 RC 69200 HCPCS outpatient 281 210.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 250.09 89 999999999 219.18 266.95 percent of total billed charges UNLISTED AMBULANCE SERVICE 9512608_1 CDM 540 RC A0999 HCPCS outpatient 1077 807.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 969.3 90 999999999 840.06 1023.15 percent of total billed charges UNLISTED AMBULANCE SERVICE 9512608_1 CDM 540 RC A0999 HCPCS outpatient 1077 807.75 AETNA MCR ADV AETNA MCR ADV 840.06 78 999999999 840.06 1023.15 percent of total billed charges UNLISTED AMBULANCE SERVICE 9512608_1 CDM 540 RC A0999 HCPCS outpatient 1077 807.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 943.13 87.57 999999999 840.06 1023.15 percent of total billed charges UNLISTED AMBULANCE SERVICE 9512608_1 CDM 540 RC A0999 HCPCS outpatient 1077 807.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 916.2 85.07 999999999 840.06 1023.15 percent of total billed charges UNLISTED AMBULANCE SERVICE 9512608_1 CDM 540 RC A0999 HCPCS outpatient 1077 807.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 916.2 85.07 999999999 840.06 1023.15 percent of total billed charges UNLISTED AMBULANCE SERVICE 9512608_1 CDM 540 RC A0999 HCPCS outpatient 1077 807.75 MOLINA MCAID MOLINA MCAID 898.22 83.4 999999999 840.06 1023.15 percent of total billed charges UNLISTED AMBULANCE SERVICE 9512608_1 CDM 540 RC A0999 HCPCS outpatient 1077 807.75 MOLINA MCR ADV MOLINA MCR ADV 958.53 89 999999999 840.06 1023.15 percent of total billed charges UNLISTED AMBULANCE SERVICE 9512608_1 CDM 540 RC A0999 HCPCS outpatient 1077 807.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 958.53 89 999999999 840.06 1023.15 percent of total billed charges UNLISTED AMBULANCE SERVICE 9512608_1 CDM 540 RC A0999 HCPCS outpatient 1077 807.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 958.53 89 999999999 840.06 1023.15 percent of total billed charges UNLISTED AMBULANCE SERVICE 9512608_1 CDM 540 RC A0999 HCPCS outpatient 1077 807.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 969.3 90 999999999 840.06 1023.15 percent of total billed charges UNLISTED AMBULANCE SERVICE 9512608_1 CDM 540 RC A0999 HCPCS outpatient 1077 807.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1023.15 95 999999999 840.06 1023.15 percent of total billed charges UNLISTED AMBULANCE SERVICE 9512608_1 CDM 540 RC A0999 HCPCS outpatient 1077 807.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1023.15 95 999999999 840.06 1023.15 percent of total billed charges UNLISTED AMBULANCE SERVICE 9512608_1 CDM 540 RC A0999 HCPCS outpatient 1077 807.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 958.53 89 999999999 840.06 1023.15 percent of total billed charges UNLISTED AMBULANCE SERVICE 9512608_1 CDM 540 RC A0999 HCPCS outpatient 1077 807.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 947.76 88 999999999 840.06 1023.15 percent of total billed charges UNLISTED AMBULANCE SERVICE 9512608_1 CDM 540 RC A0999 HCPCS outpatient 1077 807.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 958.53 89 999999999 840.06 1023.15 percent of total billed charges "RADIOLOGIC EXAMINATION, EYE, FOR DETECTION OF FOREIGN BODY" 9512628_1 CDM 320 RC 70030 HCPCS outpatient 241 180.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 216.9 90 999999999 187.98 228.95 percent of total billed charges "RADIOLOGIC EXAMINATION, EYE, FOR DETECTION OF FOREIGN BODY" 9512628_1 CDM 320 RC 70030 HCPCS outpatient 241 180.75 AETNA MCR ADV AETNA MCR ADV 187.98 78 999999999 187.98 228.95 percent of total billed charges "RADIOLOGIC EXAMINATION, EYE, FOR DETECTION OF FOREIGN BODY" 9512628_1 CDM 320 RC 70030 HCPCS outpatient 241 180.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 211.04 87.57 999999999 187.98 228.95 percent of total billed charges "RADIOLOGIC EXAMINATION, EYE, FOR DETECTION OF FOREIGN BODY" 9512628_1 CDM 320 RC 70030 HCPCS outpatient 241 180.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 205.02 85.07 999999999 187.98 228.95 percent of total billed charges "RADIOLOGIC EXAMINATION, EYE, FOR DETECTION OF FOREIGN BODY" 9512628_1 CDM 320 RC 70030 HCPCS outpatient 241 180.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 205.02 85.07 999999999 187.98 228.95 percent of total billed charges "RADIOLOGIC EXAMINATION, EYE, FOR DETECTION OF FOREIGN BODY" 9512628_1 CDM 320 RC 70030 HCPCS outpatient 241 180.75 MOLINA MCAID MOLINA MCAID 200.99 83.4 999999999 187.98 228.95 percent of total billed charges "RADIOLOGIC EXAMINATION, EYE, FOR DETECTION OF FOREIGN BODY" 9512628_1 CDM 320 RC 70030 HCPCS outpatient 241 180.75 MOLINA MCR ADV MOLINA MCR ADV 214.49 89 999999999 187.98 228.95 percent of total billed charges "RADIOLOGIC EXAMINATION, EYE, FOR DETECTION OF FOREIGN BODY" 9512628_1 CDM 320 RC 70030 HCPCS outpatient 241 180.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 214.49 89 999999999 187.98 228.95 percent of total billed charges "RADIOLOGIC EXAMINATION, EYE, FOR DETECTION OF FOREIGN BODY" 9512628_1 CDM 320 RC 70030 HCPCS outpatient 241 180.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 214.49 89 999999999 187.98 228.95 percent of total billed charges "RADIOLOGIC EXAMINATION, EYE, FOR DETECTION OF FOREIGN BODY" 9512628_1 CDM 320 RC 70030 HCPCS outpatient 241 180.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 216.9 90 999999999 187.98 228.95 percent of total billed charges "RADIOLOGIC EXAMINATION, EYE, FOR DETECTION OF FOREIGN BODY" 9512628_1 CDM 320 RC 70030 HCPCS outpatient 241 180.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 228.95 95 999999999 187.98 228.95 percent of total billed charges "RADIOLOGIC EXAMINATION, EYE, FOR DETECTION OF FOREIGN BODY" 9512628_1 CDM 320 RC 70030 HCPCS outpatient 241 180.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 228.95 95 999999999 187.98 228.95 percent of total billed charges "RADIOLOGIC EXAMINATION, EYE, FOR DETECTION OF FOREIGN BODY" 9512628_1 CDM 320 RC 70030 HCPCS outpatient 241 180.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 214.49 89 999999999 187.98 228.95 percent of total billed charges "RADIOLOGIC EXAMINATION, EYE, FOR DETECTION OF FOREIGN BODY" 9512628_1 CDM 320 RC 70030 HCPCS outpatient 241 180.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 212.08 88 999999999 187.98 228.95 percent of total billed charges "RADIOLOGIC EXAMINATION, EYE, FOR DETECTION OF FOREIGN BODY" 9512628_1 CDM 320 RC 70030 HCPCS outpatient 241 180.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 214.49 89 999999999 187.98 228.95 percent of total billed charges "RADIOLOGIC EXAMINATION, MANDIBLE; COMPLETE, MINIMUM OF 4 VIEWS" 9512634_1 CDM 320 RC 70110 HCPCS outpatient 570 427.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 513 90 999999999 444.6 541.5 percent of total billed charges "RADIOLOGIC EXAMINATION, MANDIBLE; COMPLETE, MINIMUM OF 4 VIEWS" 9512634_1 CDM 320 RC 70110 HCPCS outpatient 570 427.5 AETNA MCR ADV AETNA MCR ADV 444.6 78 999999999 444.6 541.5 percent of total billed charges "RADIOLOGIC EXAMINATION, MANDIBLE; COMPLETE, MINIMUM OF 4 VIEWS" 9512634_1 CDM 320 RC 70110 HCPCS outpatient 570 427.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 499.15 87.57 999999999 444.6 541.5 percent of total billed charges "RADIOLOGIC EXAMINATION, MANDIBLE; COMPLETE, MINIMUM OF 4 VIEWS" 9512634_1 CDM 320 RC 70110 HCPCS outpatient 570 427.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 484.9 85.07 999999999 444.6 541.5 percent of total billed charges "RADIOLOGIC EXAMINATION, MANDIBLE; COMPLETE, MINIMUM OF 4 VIEWS" 9512634_1 CDM 320 RC 70110 HCPCS outpatient 570 427.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 484.9 85.07 999999999 444.6 541.5 percent of total billed charges "RADIOLOGIC EXAMINATION, MANDIBLE; COMPLETE, MINIMUM OF 4 VIEWS" 9512634_1 CDM 320 RC 70110 HCPCS outpatient 570 427.5 MOLINA MCAID MOLINA MCAID 475.38 83.4 999999999 444.6 541.5 percent of total billed charges "RADIOLOGIC EXAMINATION, MANDIBLE; COMPLETE, MINIMUM OF 4 VIEWS" 9512634_1 CDM 320 RC 70110 HCPCS outpatient 570 427.5 MOLINA MCR ADV MOLINA MCR ADV 507.3 89 999999999 444.6 541.5 percent of total billed charges "RADIOLOGIC EXAMINATION, MANDIBLE; COMPLETE, MINIMUM OF 4 VIEWS" 9512634_1 CDM 320 RC 70110 HCPCS outpatient 570 427.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 507.3 89 999999999 444.6 541.5 percent of total billed charges "RADIOLOGIC EXAMINATION, MANDIBLE; COMPLETE, MINIMUM OF 4 VIEWS" 9512634_1 CDM 320 RC 70110 HCPCS outpatient 570 427.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 507.3 89 999999999 444.6 541.5 percent of total billed charges "RADIOLOGIC EXAMINATION, MANDIBLE; COMPLETE, MINIMUM OF 4 VIEWS" 9512634_1 CDM 320 RC 70110 HCPCS outpatient 570 427.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 513 90 999999999 444.6 541.5 percent of total billed charges "RADIOLOGIC EXAMINATION, MANDIBLE; COMPLETE, MINIMUM OF 4 VIEWS" 9512634_1 CDM 320 RC 70110 HCPCS outpatient 570 427.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 541.5 95 999999999 444.6 541.5 percent of total billed charges "RADIOLOGIC EXAMINATION, MANDIBLE; COMPLETE, MINIMUM OF 4 VIEWS" 9512634_1 CDM 320 RC 70110 HCPCS outpatient 570 427.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 541.5 95 999999999 444.6 541.5 percent of total billed charges "RADIOLOGIC EXAMINATION, MANDIBLE; COMPLETE, MINIMUM OF 4 VIEWS" 9512634_1 CDM 320 RC 70110 HCPCS outpatient 570 427.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 507.3 89 999999999 444.6 541.5 percent of total billed charges "RADIOLOGIC EXAMINATION, MANDIBLE; COMPLETE, MINIMUM OF 4 VIEWS" 9512634_1 CDM 320 RC 70110 HCPCS outpatient 570 427.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 501.6 88 999999999 444.6 541.5 percent of total billed charges "RADIOLOGIC EXAMINATION, MANDIBLE; COMPLETE, MINIMUM OF 4 VIEWS" 9512634_1 CDM 320 RC 70110 HCPCS outpatient 570 427.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 507.3 89 999999999 444.6 541.5 percent of total billed charges "RADIOLOGIC EXAMINATION, MASTOIDS; LESS THAN 3 VIEWS PER SIDE" 9512637_1 CDM 320 RC 70120 HCPCS outpatient 242 181.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 217.8 90 999999999 188.76 229.9 percent of total billed charges "RADIOLOGIC EXAMINATION, MASTOIDS; LESS THAN 3 VIEWS PER SIDE" 9512637_1 CDM 320 RC 70120 HCPCS outpatient 242 181.5 AETNA MCR ADV AETNA MCR ADV 188.76 78 999999999 188.76 229.9 percent of total billed charges "RADIOLOGIC EXAMINATION, MASTOIDS; LESS THAN 3 VIEWS PER SIDE" 9512637_1 CDM 320 RC 70120 HCPCS outpatient 242 181.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 211.92 87.57 999999999 188.76 229.9 percent of total billed charges "RADIOLOGIC EXAMINATION, MASTOIDS; LESS THAN 3 VIEWS PER SIDE" 9512637_1 CDM 320 RC 70120 HCPCS outpatient 242 181.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 205.87 85.07 999999999 188.76 229.9 percent of total billed charges "RADIOLOGIC EXAMINATION, MASTOIDS; LESS THAN 3 VIEWS PER SIDE" 9512637_1 CDM 320 RC 70120 HCPCS outpatient 242 181.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 205.87 85.07 999999999 188.76 229.9 percent of total billed charges "RADIOLOGIC EXAMINATION, MASTOIDS; LESS THAN 3 VIEWS PER SIDE" 9512637_1 CDM 320 RC 70120 HCPCS outpatient 242 181.5 MOLINA MCAID MOLINA MCAID 201.83 83.4 999999999 188.76 229.9 percent of total billed charges "RADIOLOGIC EXAMINATION, MASTOIDS; LESS THAN 3 VIEWS PER SIDE" 9512637_1 CDM 320 RC 70120 HCPCS outpatient 242 181.5 MOLINA MCR ADV MOLINA MCR ADV 215.38 89 999999999 188.76 229.9 percent of total billed charges "RADIOLOGIC EXAMINATION, MASTOIDS; LESS THAN 3 VIEWS PER SIDE" 9512637_1 CDM 320 RC 70120 HCPCS outpatient 242 181.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 215.38 89 999999999 188.76 229.9 percent of total billed charges "RADIOLOGIC EXAMINATION, MASTOIDS; LESS THAN 3 VIEWS PER SIDE" 9512637_1 CDM 320 RC 70120 HCPCS outpatient 242 181.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 215.38 89 999999999 188.76 229.9 percent of total billed charges "RADIOLOGIC EXAMINATION, MASTOIDS; LESS THAN 3 VIEWS PER SIDE" 9512637_1 CDM 320 RC 70120 HCPCS outpatient 242 181.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 217.8 90 999999999 188.76 229.9 percent of total billed charges "RADIOLOGIC EXAMINATION, MASTOIDS; LESS THAN 3 VIEWS PER SIDE" 9512637_1 CDM 320 RC 70120 HCPCS outpatient 242 181.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 229.9 95 999999999 188.76 229.9 percent of total billed charges "RADIOLOGIC EXAMINATION, MASTOIDS; LESS THAN 3 VIEWS PER SIDE" 9512637_1 CDM 320 RC 70120 HCPCS outpatient 242 181.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 229.9 95 999999999 188.76 229.9 percent of total billed charges "RADIOLOGIC EXAMINATION, MASTOIDS; LESS THAN 3 VIEWS PER SIDE" 9512637_1 CDM 320 RC 70120 HCPCS outpatient 242 181.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 215.38 89 999999999 188.76 229.9 percent of total billed charges "RADIOLOGIC EXAMINATION, MASTOIDS; LESS THAN 3 VIEWS PER SIDE" 9512637_1 CDM 320 RC 70120 HCPCS outpatient 242 181.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 212.96 88 999999999 188.76 229.9 percent of total billed charges "RADIOLOGIC EXAMINATION, MASTOIDS; LESS THAN 3 VIEWS PER SIDE" 9512637_1 CDM 320 RC 70120 HCPCS outpatient 242 181.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 215.38 89 999999999 188.76 229.9 percent of total billed charges "RADIOLOGIC EXAMINATION, FACIAL BONES; LESS THAN 3 VIEWS" 9512643_1 CDM 320 RC 70140 HCPCS outpatient 505 378.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 429.6 85.07 999999999 393.9 479.75 percent of total billed charges "RADIOLOGIC EXAMINATION, FACIAL BONES; LESS THAN 3 VIEWS" 9512643_1 CDM 320 RC 70140 HCPCS outpatient 505 378.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 429.6 85.07 999999999 393.9 479.75 percent of total billed charges "RADIOLOGIC EXAMINATION, FACIAL BONES; LESS THAN 3 VIEWS" 9512643_1 CDM 320 RC 70140 HCPCS outpatient 505 378.75 MOLINA MCAID MOLINA MCAID 421.17 83.4 999999999 393.9 479.75 percent of total billed charges "RADIOLOGIC EXAMINATION, FACIAL BONES; LESS THAN 3 VIEWS" 9512643_1 CDM 320 RC 70140 HCPCS outpatient 505 378.75 MOLINA MCR ADV MOLINA MCR ADV 449.45 89 999999999 393.9 479.75 percent of total billed charges "RADIOLOGIC EXAMINATION, FACIAL BONES; LESS THAN 3 VIEWS" 9512643_1 CDM 320 RC 70140 HCPCS outpatient 505 378.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 449.45 89 999999999 393.9 479.75 percent of total billed charges "RADIOLOGIC EXAMINATION, FACIAL BONES; LESS THAN 3 VIEWS" 9512643_1 CDM 320 RC 70140 HCPCS outpatient 505 378.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 449.45 89 999999999 393.9 479.75 percent of total billed charges "RADIOLOGIC EXAMINATION, FACIAL BONES; LESS THAN 3 VIEWS" 9512643_1 CDM 320 RC 70140 HCPCS outpatient 505 378.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 454.5 90 999999999 393.9 479.75 percent of total billed charges "RADIOLOGIC EXAMINATION, FACIAL BONES; LESS THAN 3 VIEWS" 9512643_1 CDM 320 RC 70140 HCPCS outpatient 505 378.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 479.75 95 999999999 393.9 479.75 percent of total billed charges "RADIOLOGIC EXAMINATION, FACIAL BONES; LESS THAN 3 VIEWS" 9512643_1 CDM 320 RC 70140 HCPCS outpatient 505 378.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 479.75 95 999999999 393.9 479.75 percent of total billed charges "RADIOLOGIC EXAMINATION, FACIAL BONES; LESS THAN 3 VIEWS" 9512643_1 CDM 320 RC 70140 HCPCS outpatient 505 378.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 449.45 89 999999999 393.9 479.75 percent of total billed charges "RADIOLOGIC EXAMINATION, FACIAL BONES; LESS THAN 3 VIEWS" 9512643_1 CDM 320 RC 70140 HCPCS outpatient 505 378.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 444.4 88 999999999 393.9 479.75 percent of total billed charges "RADIOLOGIC EXAMINATION, FACIAL BONES; LESS THAN 3 VIEWS" 9512643_1 CDM 320 RC 70140 HCPCS outpatient 505 378.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 449.45 89 999999999 393.9 479.75 percent of total billed charges "RADIOLOGIC EXAMINATION, FACIAL BONES; LESS THAN 3 VIEWS" 9512643_1 CDM 320 RC 70140 HCPCS outpatient 505 378.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 454.5 90 999999999 393.9 479.75 percent of total billed charges "RADIOLOGIC EXAMINATION, FACIAL BONES; LESS THAN 3 VIEWS" 9512643_1 CDM 320 RC 70140 HCPCS outpatient 505 378.75 AETNA MCR ADV AETNA MCR ADV 393.9 78 999999999 393.9 479.75 percent of total billed charges "RADIOLOGIC EXAMINATION, FACIAL BONES; LESS THAN 3 VIEWS" 9512643_1 CDM 320 RC 70140 HCPCS outpatient 505 378.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 442.23 87.57 999999999 393.9 479.75 percent of total billed charges "RADIOLOGIC EXAMINATION, FACIAL BONES; COMPLETE, MINIMUM OF 3 VIEWS" 9512646_1 CDM 320 RC 70150 HCPCS outpatient 554 415.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 498.6 90 999999999 432.12 526.3 percent of total billed charges "RADIOLOGIC EXAMINATION, FACIAL BONES; COMPLETE, MINIMUM OF 3 VIEWS" 9512646_1 CDM 320 RC 70150 HCPCS outpatient 554 415.5 AETNA MCR ADV AETNA MCR ADV 432.12 78 999999999 432.12 526.3 percent of total billed charges "RADIOLOGIC EXAMINATION, FACIAL BONES; COMPLETE, MINIMUM OF 3 VIEWS" 9512646_1 CDM 320 RC 70150 HCPCS outpatient 554 415.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 485.14 87.57 999999999 432.12 526.3 percent of total billed charges "RADIOLOGIC EXAMINATION, FACIAL BONES; COMPLETE, MINIMUM OF 3 VIEWS" 9512646_1 CDM 320 RC 70150 HCPCS outpatient 554 415.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 471.29 85.07 999999999 432.12 526.3 percent of total billed charges "RADIOLOGIC EXAMINATION, FACIAL BONES; COMPLETE, MINIMUM OF 3 VIEWS" 9512646_1 CDM 320 RC 70150 HCPCS outpatient 554 415.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 471.29 85.07 999999999 432.12 526.3 percent of total billed charges "RADIOLOGIC EXAMINATION, FACIAL BONES; COMPLETE, MINIMUM OF 3 VIEWS" 9512646_1 CDM 320 RC 70150 HCPCS outpatient 554 415.5 MOLINA MCAID MOLINA MCAID 462.04 83.4 999999999 432.12 526.3 percent of total billed charges "RADIOLOGIC EXAMINATION, FACIAL BONES; COMPLETE, MINIMUM OF 3 VIEWS" 9512646_1 CDM 320 RC 70150 HCPCS outpatient 554 415.5 MOLINA MCR ADV MOLINA MCR ADV 493.06 89 999999999 432.12 526.3 percent of total billed charges "RADIOLOGIC EXAMINATION, FACIAL BONES; COMPLETE, MINIMUM OF 3 VIEWS" 9512646_1 CDM 320 RC 70150 HCPCS outpatient 554 415.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 493.06 89 999999999 432.12 526.3 percent of total billed charges "RADIOLOGIC EXAMINATION, FACIAL BONES; COMPLETE, MINIMUM OF 3 VIEWS" 9512646_1 CDM 320 RC 70150 HCPCS outpatient 554 415.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 493.06 89 999999999 432.12 526.3 percent of total billed charges "RADIOLOGIC EXAMINATION, FACIAL BONES; COMPLETE, MINIMUM OF 3 VIEWS" 9512646_1 CDM 320 RC 70150 HCPCS outpatient 554 415.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 498.6 90 999999999 432.12 526.3 percent of total billed charges "RADIOLOGIC EXAMINATION, FACIAL BONES; COMPLETE, MINIMUM OF 3 VIEWS" 9512646_1 CDM 320 RC 70150 HCPCS outpatient 554 415.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 526.3 95 999999999 432.12 526.3 percent of total billed charges "RADIOLOGIC EXAMINATION, FACIAL BONES; COMPLETE, MINIMUM OF 3 VIEWS" 9512646_1 CDM 320 RC 70150 HCPCS outpatient 554 415.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 526.3 95 999999999 432.12 526.3 percent of total billed charges "RADIOLOGIC EXAMINATION, FACIAL BONES; COMPLETE, MINIMUM OF 3 VIEWS" 9512646_1 CDM 320 RC 70150 HCPCS outpatient 554 415.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 493.06 89 999999999 432.12 526.3 percent of total billed charges "RADIOLOGIC EXAMINATION, FACIAL BONES; COMPLETE, MINIMUM OF 3 VIEWS" 9512646_1 CDM 320 RC 70150 HCPCS outpatient 554 415.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 487.52 88 999999999 432.12 526.3 percent of total billed charges "RADIOLOGIC EXAMINATION, FACIAL BONES; COMPLETE, MINIMUM OF 3 VIEWS" 9512646_1 CDM 320 RC 70150 HCPCS outpatient 554 415.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 493.06 89 999999999 432.12 526.3 percent of total billed charges "RADIOLOGIC EXAMINATION, NASAL BONES, COMPLETE, MINIMUM OF 3 VIEWS" 9512649_1 CDM 320 RC 70160 HCPCS outpatient 387 290.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 348.3 90 999999999 301.86 367.65 percent of total billed charges "RADIOLOGIC EXAMINATION, NASAL BONES, COMPLETE, MINIMUM OF 3 VIEWS" 9512649_1 CDM 320 RC 70160 HCPCS outpatient 387 290.25 AETNA MCR ADV AETNA MCR ADV 301.86 78 999999999 301.86 367.65 percent of total billed charges "RADIOLOGIC EXAMINATION, NASAL BONES, COMPLETE, MINIMUM OF 3 VIEWS" 9512649_1 CDM 320 RC 70160 HCPCS outpatient 387 290.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 338.9 87.57 999999999 301.86 367.65 percent of total billed charges "RADIOLOGIC EXAMINATION, NASAL BONES, COMPLETE, MINIMUM OF 3 VIEWS" 9512649_1 CDM 320 RC 70160 HCPCS outpatient 387 290.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 329.22 85.07 999999999 301.86 367.65 percent of total billed charges "RADIOLOGIC EXAMINATION, NASAL BONES, COMPLETE, MINIMUM OF 3 VIEWS" 9512649_1 CDM 320 RC 70160 HCPCS outpatient 387 290.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 329.22 85.07 999999999 301.86 367.65 percent of total billed charges "RADIOLOGIC EXAMINATION, NASAL BONES, COMPLETE, MINIMUM OF 3 VIEWS" 9512649_1 CDM 320 RC 70160 HCPCS outpatient 387 290.25 MOLINA MCAID MOLINA MCAID 322.76 83.4 999999999 301.86 367.65 percent of total billed charges "RADIOLOGIC EXAMINATION, NASAL BONES, COMPLETE, MINIMUM OF 3 VIEWS" 9512649_1 CDM 320 RC 70160 HCPCS outpatient 387 290.25 MOLINA MCR ADV MOLINA MCR ADV 344.43 89 999999999 301.86 367.65 percent of total billed charges "RADIOLOGIC EXAMINATION, NASAL BONES, COMPLETE, MINIMUM OF 3 VIEWS" 9512649_1 CDM 320 RC 70160 HCPCS outpatient 387 290.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 344.43 89 999999999 301.86 367.65 percent of total billed charges "RADIOLOGIC EXAMINATION, NASAL BONES, COMPLETE, MINIMUM OF 3 VIEWS" 9512649_1 CDM 320 RC 70160 HCPCS outpatient 387 290.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 344.43 89 999999999 301.86 367.65 percent of total billed charges "RADIOLOGIC EXAMINATION, NASAL BONES, COMPLETE, MINIMUM OF 3 VIEWS" 9512649_1 CDM 320 RC 70160 HCPCS outpatient 387 290.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 348.3 90 999999999 301.86 367.65 percent of total billed charges "RADIOLOGIC EXAMINATION, NASAL BONES, COMPLETE, MINIMUM OF 3 VIEWS" 9512649_1 CDM 320 RC 70160 HCPCS outpatient 387 290.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 367.65 95 999999999 301.86 367.65 percent of total billed charges "RADIOLOGIC EXAMINATION, NASAL BONES, COMPLETE, MINIMUM OF 3 VIEWS" 9512649_1 CDM 320 RC 70160 HCPCS outpatient 387 290.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 367.65 95 999999999 301.86 367.65 percent of total billed charges "RADIOLOGIC EXAMINATION, NASAL BONES, COMPLETE, MINIMUM OF 3 VIEWS" 9512649_1 CDM 320 RC 70160 HCPCS outpatient 387 290.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 344.43 89 999999999 301.86 367.65 percent of total billed charges "RADIOLOGIC EXAMINATION, NASAL BONES, COMPLETE, MINIMUM OF 3 VIEWS" 9512649_1 CDM 320 RC 70160 HCPCS outpatient 387 290.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 340.56 88 999999999 301.86 367.65 percent of total billed charges "RADIOLOGIC EXAMINATION, NASAL BONES, COMPLETE, MINIMUM OF 3 VIEWS" 9512649_1 CDM 320 RC 70160 HCPCS outpatient 387 290.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 344.43 89 999999999 301.86 367.65 percent of total billed charges "RADIOLOGIC EXAMINATION; ORBITS, COMPLETE, MINIMUM OF 4 VIEWS" 9512655_1 CDM 320 RC 70200 HCPCS outpatient 378 283.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 340.2 90 999999999 294.84 359.1 percent of total billed charges "RADIOLOGIC EXAMINATION; ORBITS, COMPLETE, MINIMUM OF 4 VIEWS" 9512655_1 CDM 320 RC 70200 HCPCS outpatient 378 283.5 AETNA MCR ADV AETNA MCR ADV 294.84 78 999999999 294.84 359.1 percent of total billed charges "RADIOLOGIC EXAMINATION; ORBITS, COMPLETE, MINIMUM OF 4 VIEWS" 9512655_1 CDM 320 RC 70200 HCPCS outpatient 378 283.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 331.01 87.57 999999999 294.84 359.1 percent of total billed charges "RADIOLOGIC EXAMINATION; ORBITS, COMPLETE, MINIMUM OF 4 VIEWS" 9512655_1 CDM 320 RC 70200 HCPCS outpatient 378 283.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 321.56 85.07 999999999 294.84 359.1 percent of total billed charges "RADIOLOGIC EXAMINATION; ORBITS, COMPLETE, MINIMUM OF 4 VIEWS" 9512655_1 CDM 320 RC 70200 HCPCS outpatient 378 283.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 321.56 85.07 999999999 294.84 359.1 percent of total billed charges "RADIOLOGIC EXAMINATION; ORBITS, COMPLETE, MINIMUM OF 4 VIEWS" 9512655_1 CDM 320 RC 70200 HCPCS outpatient 378 283.5 MOLINA MCAID MOLINA MCAID 315.25 83.4 999999999 294.84 359.1 percent of total billed charges "RADIOLOGIC EXAMINATION; ORBITS, COMPLETE, MINIMUM OF 4 VIEWS" 9512655_1 CDM 320 RC 70200 HCPCS outpatient 378 283.5 MOLINA MCR ADV MOLINA MCR ADV 336.42 89 999999999 294.84 359.1 percent of total billed charges "RADIOLOGIC EXAMINATION; ORBITS, COMPLETE, MINIMUM OF 4 VIEWS" 9512655_1 CDM 320 RC 70200 HCPCS outpatient 378 283.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 336.42 89 999999999 294.84 359.1 percent of total billed charges "RADIOLOGIC EXAMINATION; ORBITS, COMPLETE, MINIMUM OF 4 VIEWS" 9512655_1 CDM 320 RC 70200 HCPCS outpatient 378 283.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 336.42 89 999999999 294.84 359.1 percent of total billed charges "RADIOLOGIC EXAMINATION; ORBITS, COMPLETE, MINIMUM OF 4 VIEWS" 9512655_1 CDM 320 RC 70200 HCPCS outpatient 378 283.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 340.2 90 999999999 294.84 359.1 percent of total billed charges "RADIOLOGIC EXAMINATION; ORBITS, COMPLETE, MINIMUM OF 4 VIEWS" 9512655_1 CDM 320 RC 70200 HCPCS outpatient 378 283.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 359.1 95 999999999 294.84 359.1 percent of total billed charges "RADIOLOGIC EXAMINATION; ORBITS, COMPLETE, MINIMUM OF 4 VIEWS" 9512655_1 CDM 320 RC 70200 HCPCS outpatient 378 283.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 359.1 95 999999999 294.84 359.1 percent of total billed charges "RADIOLOGIC EXAMINATION; ORBITS, COMPLETE, MINIMUM OF 4 VIEWS" 9512655_1 CDM 320 RC 70200 HCPCS outpatient 378 283.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 336.42 89 999999999 294.84 359.1 percent of total billed charges "RADIOLOGIC EXAMINATION; ORBITS, COMPLETE, MINIMUM OF 4 VIEWS" 9512655_1 CDM 320 RC 70200 HCPCS outpatient 378 283.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 332.64 88 999999999 294.84 359.1 percent of total billed charges "RADIOLOGIC EXAMINATION; ORBITS, COMPLETE, MINIMUM OF 4 VIEWS" 9512655_1 CDM 320 RC 70200 HCPCS outpatient 378 283.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 336.42 89 999999999 294.84 359.1 percent of total billed charges "RADIOLOGIC EXAMINATION, SINUSES, PARANASAL, COMPLETE, MINIMUM OF 3 VIEWS" 9512661_1 CDM 320 RC 70220 HCPCS outpatient 423 317.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 380.7 90 999999999 329.94 401.85 percent of total billed charges "RADIOLOGIC EXAMINATION, SINUSES, PARANASAL, COMPLETE, MINIMUM OF 3 VIEWS" 9512661_1 CDM 320 RC 70220 HCPCS outpatient 423 317.25 AETNA MCR ADV AETNA MCR ADV 329.94 78 999999999 329.94 401.85 percent of total billed charges "RADIOLOGIC EXAMINATION, SINUSES, PARANASAL, COMPLETE, MINIMUM OF 3 VIEWS" 9512661_1 CDM 320 RC 70220 HCPCS outpatient 423 317.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 370.42 87.57 999999999 329.94 401.85 percent of total billed charges "RADIOLOGIC EXAMINATION, SINUSES, PARANASAL, COMPLETE, MINIMUM OF 3 VIEWS" 9512661_1 CDM 320 RC 70220 HCPCS outpatient 423 317.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 359.85 85.07 999999999 329.94 401.85 percent of total billed charges "RADIOLOGIC EXAMINATION, SINUSES, PARANASAL, COMPLETE, MINIMUM OF 3 VIEWS" 9512661_1 CDM 320 RC 70220 HCPCS outpatient 423 317.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 359.85 85.07 999999999 329.94 401.85 percent of total billed charges "RADIOLOGIC EXAMINATION, SINUSES, PARANASAL, COMPLETE, MINIMUM OF 3 VIEWS" 9512661_1 CDM 320 RC 70220 HCPCS outpatient 423 317.25 MOLINA MCAID MOLINA MCAID 352.78 83.4 999999999 329.94 401.85 percent of total billed charges "RADIOLOGIC EXAMINATION, SINUSES, PARANASAL, COMPLETE, MINIMUM OF 3 VIEWS" 9512661_1 CDM 320 RC 70220 HCPCS outpatient 423 317.25 MOLINA MCR ADV MOLINA MCR ADV 376.47 89 999999999 329.94 401.85 percent of total billed charges "RADIOLOGIC EXAMINATION, SINUSES, PARANASAL, COMPLETE, MINIMUM OF 3 VIEWS" 9512661_1 CDM 320 RC 70220 HCPCS outpatient 423 317.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 376.47 89 999999999 329.94 401.85 percent of total billed charges "RADIOLOGIC EXAMINATION, SINUSES, PARANASAL, COMPLETE, MINIMUM OF 3 VIEWS" 9512661_1 CDM 320 RC 70220 HCPCS outpatient 423 317.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 376.47 89 999999999 329.94 401.85 percent of total billed charges "RADIOLOGIC EXAMINATION, SINUSES, PARANASAL, COMPLETE, MINIMUM OF 3 VIEWS" 9512661_1 CDM 320 RC 70220 HCPCS outpatient 423 317.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 380.7 90 999999999 329.94 401.85 percent of total billed charges "RADIOLOGIC EXAMINATION, SINUSES, PARANASAL, COMPLETE, MINIMUM OF 3 VIEWS" 9512661_1 CDM 320 RC 70220 HCPCS outpatient 423 317.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 401.85 95 999999999 329.94 401.85 percent of total billed charges "RADIOLOGIC EXAMINATION, SINUSES, PARANASAL, COMPLETE, MINIMUM OF 3 VIEWS" 9512661_1 CDM 320 RC 70220 HCPCS outpatient 423 317.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 401.85 95 999999999 329.94 401.85 percent of total billed charges "RADIOLOGIC EXAMINATION, SINUSES, PARANASAL, COMPLETE, MINIMUM OF 3 VIEWS" 9512661_1 CDM 320 RC 70220 HCPCS outpatient 423 317.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 376.47 89 999999999 329.94 401.85 percent of total billed charges "RADIOLOGIC EXAMINATION, SINUSES, PARANASAL, COMPLETE, MINIMUM OF 3 VIEWS" 9512661_1 CDM 320 RC 70220 HCPCS outpatient 423 317.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 372.24 88 999999999 329.94 401.85 percent of total billed charges "RADIOLOGIC EXAMINATION, SINUSES, PARANASAL, COMPLETE, MINIMUM OF 3 VIEWS" 9512661_1 CDM 320 RC 70220 HCPCS outpatient 423 317.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 376.47 89 999999999 329.94 401.85 percent of total billed charges "RADIOLOGIC EXAMINATION, SKULL; LESS THAN 4 VIEWS" 9512667_1 CDM 320 RC 70250 HCPCS outpatient 405 303.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 364.5 90 999999999 315.9 384.75 percent of total billed charges "RADIOLOGIC EXAMINATION, SKULL; LESS THAN 4 VIEWS" 9512667_1 CDM 320 RC 70250 HCPCS outpatient 405 303.75 AETNA MCR ADV AETNA MCR ADV 315.9 78 999999999 315.9 384.75 percent of total billed charges "RADIOLOGIC EXAMINATION, SKULL; LESS THAN 4 VIEWS" 9512667_1 CDM 320 RC 70250 HCPCS outpatient 405 303.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 354.66 87.57 999999999 315.9 384.75 percent of total billed charges "RADIOLOGIC EXAMINATION, SKULL; LESS THAN 4 VIEWS" 9512667_1 CDM 320 RC 70250 HCPCS outpatient 405 303.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 344.53 85.07 999999999 315.9 384.75 percent of total billed charges "RADIOLOGIC EXAMINATION, SKULL; LESS THAN 4 VIEWS" 9512667_1 CDM 320 RC 70250 HCPCS outpatient 405 303.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 344.53 85.07 999999999 315.9 384.75 percent of total billed charges "RADIOLOGIC EXAMINATION, SKULL; LESS THAN 4 VIEWS" 9512667_1 CDM 320 RC 70250 HCPCS outpatient 405 303.75 MOLINA MCAID MOLINA MCAID 337.77 83.4 999999999 315.9 384.75 percent of total billed charges "RADIOLOGIC EXAMINATION, SKULL; LESS THAN 4 VIEWS" 9512667_1 CDM 320 RC 70250 HCPCS outpatient 405 303.75 MOLINA MCR ADV MOLINA MCR ADV 360.45 89 999999999 315.9 384.75 percent of total billed charges "RADIOLOGIC EXAMINATION, SKULL; LESS THAN 4 VIEWS" 9512667_1 CDM 320 RC 70250 HCPCS outpatient 405 303.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 360.45 89 999999999 315.9 384.75 percent of total billed charges "RADIOLOGIC EXAMINATION, SKULL; LESS THAN 4 VIEWS" 9512667_1 CDM 320 RC 70250 HCPCS outpatient 405 303.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 360.45 89 999999999 315.9 384.75 percent of total billed charges "RADIOLOGIC EXAMINATION, SKULL; LESS THAN 4 VIEWS" 9512667_1 CDM 320 RC 70250 HCPCS outpatient 405 303.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 364.5 90 999999999 315.9 384.75 percent of total billed charges "RADIOLOGIC EXAMINATION, SKULL; LESS THAN 4 VIEWS" 9512667_1 CDM 320 RC 70250 HCPCS outpatient 405 303.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 384.75 95 999999999 315.9 384.75 percent of total billed charges "RADIOLOGIC EXAMINATION, SKULL; LESS THAN 4 VIEWS" 9512667_1 CDM 320 RC 70250 HCPCS outpatient 405 303.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 384.75 95 999999999 315.9 384.75 percent of total billed charges "RADIOLOGIC EXAMINATION, SKULL; LESS THAN 4 VIEWS" 9512667_1 CDM 320 RC 70250 HCPCS outpatient 405 303.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 360.45 89 999999999 315.9 384.75 percent of total billed charges "RADIOLOGIC EXAMINATION, SKULL; LESS THAN 4 VIEWS" 9512667_1 CDM 320 RC 70250 HCPCS outpatient 405 303.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 356.4 88 999999999 315.9 384.75 percent of total billed charges "RADIOLOGIC EXAMINATION, SKULL; LESS THAN 4 VIEWS" 9512667_1 CDM 320 RC 70250 HCPCS outpatient 405 303.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 360.45 89 999999999 315.9 384.75 percent of total billed charges "RADIOLOGIC EXAMINATION, SKULL; COMPLETE, MINIMUM OF 4 VIEWS" 9512670_1 CDM 320 RC 70260 HCPCS outpatient 478 358.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 430.2 90 999999999 372.84 454.1 percent of total billed charges "RADIOLOGIC EXAMINATION, SKULL; COMPLETE, MINIMUM OF 4 VIEWS" 9512670_1 CDM 320 RC 70260 HCPCS outpatient 478 358.5 AETNA MCR ADV AETNA MCR ADV 372.84 78 999999999 372.84 454.1 percent of total billed charges "RADIOLOGIC EXAMINATION, SKULL; COMPLETE, MINIMUM OF 4 VIEWS" 9512670_1 CDM 320 RC 70260 HCPCS outpatient 478 358.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 418.58 87.57 999999999 372.84 454.1 percent of total billed charges "RADIOLOGIC EXAMINATION, SKULL; COMPLETE, MINIMUM OF 4 VIEWS" 9512670_1 CDM 320 RC 70260 HCPCS outpatient 478 358.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 406.63 85.07 999999999 372.84 454.1 percent of total billed charges "RADIOLOGIC EXAMINATION, SKULL; COMPLETE, MINIMUM OF 4 VIEWS" 9512670_1 CDM 320 RC 70260 HCPCS outpatient 478 358.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 406.63 85.07 999999999 372.84 454.1 percent of total billed charges "RADIOLOGIC EXAMINATION, SKULL; COMPLETE, MINIMUM OF 4 VIEWS" 9512670_1 CDM 320 RC 70260 HCPCS outpatient 478 358.5 MOLINA MCAID MOLINA MCAID 398.65 83.4 999999999 372.84 454.1 percent of total billed charges "RADIOLOGIC EXAMINATION, SKULL; COMPLETE, MINIMUM OF 4 VIEWS" 9512670_1 CDM 320 RC 70260 HCPCS outpatient 478 358.5 MOLINA MCR ADV MOLINA MCR ADV 425.42 89 999999999 372.84 454.1 percent of total billed charges "RADIOLOGIC EXAMINATION, SKULL; COMPLETE, MINIMUM OF 4 VIEWS" 9512670_1 CDM 320 RC 70260 HCPCS outpatient 478 358.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 425.42 89 999999999 372.84 454.1 percent of total billed charges "RADIOLOGIC EXAMINATION, SKULL; COMPLETE, MINIMUM OF 4 VIEWS" 9512670_1 CDM 320 RC 70260 HCPCS outpatient 478 358.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 425.42 89 999999999 372.84 454.1 percent of total billed charges "RADIOLOGIC EXAMINATION, SKULL; COMPLETE, MINIMUM OF 4 VIEWS" 9512670_1 CDM 320 RC 70260 HCPCS outpatient 478 358.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 430.2 90 999999999 372.84 454.1 percent of total billed charges "RADIOLOGIC EXAMINATION, SKULL; COMPLETE, MINIMUM OF 4 VIEWS" 9512670_1 CDM 320 RC 70260 HCPCS outpatient 478 358.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 454.1 95 999999999 372.84 454.1 percent of total billed charges "RADIOLOGIC EXAMINATION, SKULL; COMPLETE, MINIMUM OF 4 VIEWS" 9512670_1 CDM 320 RC 70260 HCPCS outpatient 478 358.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 454.1 95 999999999 372.84 454.1 percent of total billed charges "RADIOLOGIC EXAMINATION, SKULL; COMPLETE, MINIMUM OF 4 VIEWS" 9512670_1 CDM 320 RC 70260 HCPCS outpatient 478 358.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 425.42 89 999999999 372.84 454.1 percent of total billed charges "RADIOLOGIC EXAMINATION, SKULL; COMPLETE, MINIMUM OF 4 VIEWS" 9512670_1 CDM 320 RC 70260 HCPCS outpatient 478 358.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 420.64 88 999999999 372.84 454.1 percent of total billed charges "RADIOLOGIC EXAMINATION, SKULL; COMPLETE, MINIMUM OF 4 VIEWS" 9512670_1 CDM 320 RC 70260 HCPCS outpatient 478 358.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 425.42 89 999999999 372.84 454.1 percent of total billed charges "RADIOLOGIC EXAMINATION, TEMPOROMANDIBULAR JOINT, OPEN AND CLOSED MOUTH; BILATERAL" 9512676_1 CDM 320 RC 70330 HCPCS outpatient 417 312.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 375.3 90 999999999 325.26 396.15 percent of total billed charges "RADIOLOGIC EXAMINATION, TEMPOROMANDIBULAR JOINT, OPEN AND CLOSED MOUTH; BILATERAL" 9512676_1 CDM 320 RC 70330 HCPCS outpatient 417 312.75 AETNA MCR ADV AETNA MCR ADV 325.26 78 999999999 325.26 396.15 percent of total billed charges "RADIOLOGIC EXAMINATION, TEMPOROMANDIBULAR JOINT, OPEN AND CLOSED MOUTH; BILATERAL" 9512676_1 CDM 320 RC 70330 HCPCS outpatient 417 312.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 365.17 87.57 999999999 325.26 396.15 percent of total billed charges "RADIOLOGIC EXAMINATION, TEMPOROMANDIBULAR JOINT, OPEN AND CLOSED MOUTH; BILATERAL" 9512676_1 CDM 320 RC 70330 HCPCS outpatient 417 312.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 354.74 85.07 999999999 325.26 396.15 percent of total billed charges "RADIOLOGIC EXAMINATION, TEMPOROMANDIBULAR JOINT, OPEN AND CLOSED MOUTH; BILATERAL" 9512676_1 CDM 320 RC 70330 HCPCS outpatient 417 312.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 354.74 85.07 999999999 325.26 396.15 percent of total billed charges "RADIOLOGIC EXAMINATION, TEMPOROMANDIBULAR JOINT, OPEN AND CLOSED MOUTH; BILATERAL" 9512676_1 CDM 320 RC 70330 HCPCS outpatient 417 312.75 MOLINA MCAID MOLINA MCAID 347.78 83.4 999999999 325.26 396.15 percent of total billed charges "RADIOLOGIC EXAMINATION, TEMPOROMANDIBULAR JOINT, OPEN AND CLOSED MOUTH; BILATERAL" 9512676_1 CDM 320 RC 70330 HCPCS outpatient 417 312.75 MOLINA MCR ADV MOLINA MCR ADV 371.13 89 999999999 325.26 396.15 percent of total billed charges "RADIOLOGIC EXAMINATION, TEMPOROMANDIBULAR JOINT, OPEN AND CLOSED MOUTH; BILATERAL" 9512676_1 CDM 320 RC 70330 HCPCS outpatient 417 312.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 371.13 89 999999999 325.26 396.15 percent of total billed charges "RADIOLOGIC EXAMINATION, TEMPOROMANDIBULAR JOINT, OPEN AND CLOSED MOUTH; BILATERAL" 9512676_1 CDM 320 RC 70330 HCPCS outpatient 417 312.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 371.13 89 999999999 325.26 396.15 percent of total billed charges "RADIOLOGIC EXAMINATION, TEMPOROMANDIBULAR JOINT, OPEN AND CLOSED MOUTH; BILATERAL" 9512676_1 CDM 320 RC 70330 HCPCS outpatient 417 312.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 375.3 90 999999999 325.26 396.15 percent of total billed charges "RADIOLOGIC EXAMINATION, TEMPOROMANDIBULAR JOINT, OPEN AND CLOSED MOUTH; BILATERAL" 9512676_1 CDM 320 RC 70330 HCPCS outpatient 417 312.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 396.15 95 999999999 325.26 396.15 percent of total billed charges "RADIOLOGIC EXAMINATION, TEMPOROMANDIBULAR JOINT, OPEN AND CLOSED MOUTH; BILATERAL" 9512676_1 CDM 320 RC 70330 HCPCS outpatient 417 312.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 396.15 95 999999999 325.26 396.15 percent of total billed charges "RADIOLOGIC EXAMINATION, TEMPOROMANDIBULAR JOINT, OPEN AND CLOSED MOUTH; BILATERAL" 9512676_1 CDM 320 RC 70330 HCPCS outpatient 417 312.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 371.13 89 999999999 325.26 396.15 percent of total billed charges "RADIOLOGIC EXAMINATION, TEMPOROMANDIBULAR JOINT, OPEN AND CLOSED MOUTH; BILATERAL" 9512676_1 CDM 320 RC 70330 HCPCS outpatient 417 312.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 366.96 88 999999999 325.26 396.15 percent of total billed charges "RADIOLOGIC EXAMINATION, TEMPOROMANDIBULAR JOINT, OPEN AND CLOSED MOUTH; BILATERAL" 9512676_1 CDM 320 RC 70330 HCPCS outpatient 417 312.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 371.13 89 999999999 325.26 396.15 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, TEMPOROMANDIBULAR JOINT(S)" 9512679_1 CDM 610 RC 70336 HCPCS outpatient 3256 2442 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 2930.4 90 999999999 2539.68 3093.2 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, TEMPOROMANDIBULAR JOINT(S)" 9512679_1 CDM 610 RC 70336 HCPCS outpatient 3256 2442 AETNA MCR ADV AETNA MCR ADV 2539.68 78 999999999 2539.68 3093.2 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, TEMPOROMANDIBULAR JOINT(S)" 9512679_1 CDM 610 RC 70336 HCPCS outpatient 3256 2442 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 2851.28 87.57 999999999 2539.68 3093.2 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, TEMPOROMANDIBULAR JOINT(S)" 9512679_1 CDM 610 RC 70336 HCPCS outpatient 3256 2442 COORDINATED CARE MCAID COORDINATED CARE MCAID 2769.88 85.07 999999999 2539.68 3093.2 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, TEMPOROMANDIBULAR JOINT(S)" 9512679_1 CDM 610 RC 70336 HCPCS outpatient 3256 2442 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 2769.88 85.07 999999999 2539.68 3093.2 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, TEMPOROMANDIBULAR JOINT(S)" 9512679_1 CDM 610 RC 70336 HCPCS outpatient 3256 2442 MOLINA MCAID MOLINA MCAID 2715.5 83.4 999999999 2539.68 3093.2 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, TEMPOROMANDIBULAR JOINT(S)" 9512679_1 CDM 610 RC 70336 HCPCS outpatient 3256 2442 MOLINA MCR ADV MOLINA MCR ADV 2897.84 89 999999999 2539.68 3093.2 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, TEMPOROMANDIBULAR JOINT(S)" 9512679_1 CDM 610 RC 70336 HCPCS outpatient 3256 2442 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 2897.84 89 999999999 2539.68 3093.2 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, TEMPOROMANDIBULAR JOINT(S)" 9512679_1 CDM 610 RC 70336 HCPCS outpatient 3256 2442 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 2897.84 89 999999999 2539.68 3093.2 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, TEMPOROMANDIBULAR JOINT(S)" 9512679_1 CDM 610 RC 70336 HCPCS outpatient 3256 2442 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 2930.4 90 999999999 2539.68 3093.2 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, TEMPOROMANDIBULAR JOINT(S)" 9512679_1 CDM 610 RC 70336 HCPCS outpatient 3256 2442 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 3093.2 95 999999999 2539.68 3093.2 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, TEMPOROMANDIBULAR JOINT(S)" 9512679_1 CDM 610 RC 70336 HCPCS outpatient 3256 2442 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 3093.2 95 999999999 2539.68 3093.2 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, TEMPOROMANDIBULAR JOINT(S)" 9512679_1 CDM 610 RC 70336 HCPCS outpatient 3256 2442 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 2897.84 89 999999999 2539.68 3093.2 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, TEMPOROMANDIBULAR JOINT(S)" 9512679_1 CDM 610 RC 70336 HCPCS outpatient 3256 2442 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 2865.28 88 999999999 2539.68 3093.2 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, TEMPOROMANDIBULAR JOINT(S)" 9512679_1 CDM 610 RC 70336 HCPCS outpatient 3256 2442 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 2897.84 89 999999999 2539.68 3093.2 percent of total billed charges "RADIOLOGIC EXAMINATION; NECK, SOFT TISSUE" 9512682_1 CDM 320 RC 70360 HCPCS outpatient 295 221.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 265.5 90 999999999 230.1 280.25 percent of total billed charges "RADIOLOGIC EXAMINATION; NECK, SOFT TISSUE" 9512682_1 CDM 320 RC 70360 HCPCS outpatient 295 221.25 AETNA MCR ADV AETNA MCR ADV 230.1 78 999999999 230.1 280.25 percent of total billed charges "RADIOLOGIC EXAMINATION; NECK, SOFT TISSUE" 9512682_1 CDM 320 RC 70360 HCPCS outpatient 295 221.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 258.33 87.57 999999999 230.1 280.25 percent of total billed charges "RADIOLOGIC EXAMINATION; NECK, SOFT TISSUE" 9512682_1 CDM 320 RC 70360 HCPCS outpatient 295 221.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 250.96 85.07 999999999 230.1 280.25 percent of total billed charges "RADIOLOGIC EXAMINATION; NECK, SOFT TISSUE" 9512682_1 CDM 320 RC 70360 HCPCS outpatient 295 221.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 250.96 85.07 999999999 230.1 280.25 percent of total billed charges "RADIOLOGIC EXAMINATION; NECK, SOFT TISSUE" 9512682_1 CDM 320 RC 70360 HCPCS outpatient 295 221.25 MOLINA MCAID MOLINA MCAID 246.03 83.4 999999999 230.1 280.25 percent of total billed charges "RADIOLOGIC EXAMINATION; NECK, SOFT TISSUE" 9512682_1 CDM 320 RC 70360 HCPCS outpatient 295 221.25 MOLINA MCR ADV MOLINA MCR ADV 262.55 89 999999999 230.1 280.25 percent of total billed charges "RADIOLOGIC EXAMINATION; NECK, SOFT TISSUE" 9512682_1 CDM 320 RC 70360 HCPCS outpatient 295 221.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 262.55 89 999999999 230.1 280.25 percent of total billed charges "RADIOLOGIC EXAMINATION; NECK, SOFT TISSUE" 9512682_1 CDM 320 RC 70360 HCPCS outpatient 295 221.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 262.55 89 999999999 230.1 280.25 percent of total billed charges "RADIOLOGIC EXAMINATION; NECK, SOFT TISSUE" 9512682_1 CDM 320 RC 70360 HCPCS outpatient 295 221.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 265.5 90 999999999 230.1 280.25 percent of total billed charges "RADIOLOGIC EXAMINATION; NECK, SOFT TISSUE" 9512682_1 CDM 320 RC 70360 HCPCS outpatient 295 221.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 280.25 95 999999999 230.1 280.25 percent of total billed charges "RADIOLOGIC EXAMINATION; NECK, SOFT TISSUE" 9512682_1 CDM 320 RC 70360 HCPCS outpatient 295 221.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 280.25 95 999999999 230.1 280.25 percent of total billed charges "RADIOLOGIC EXAMINATION; NECK, SOFT TISSUE" 9512682_1 CDM 320 RC 70360 HCPCS outpatient 295 221.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 262.55 89 999999999 230.1 280.25 percent of total billed charges "RADIOLOGIC EXAMINATION; NECK, SOFT TISSUE" 9512682_1 CDM 320 RC 70360 HCPCS outpatient 295 221.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 259.6 88 999999999 230.1 280.25 percent of total billed charges "RADIOLOGIC EXAMINATION; NECK, SOFT TISSUE" 9512682_1 CDM 320 RC 70360 HCPCS outpatient 295 221.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 262.55 89 999999999 230.1 280.25 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL" 9512694_1 CDM 351 RC 70450 HCPCS outpatient 1499 1124.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1349.1 90 999999999 1169.22 1424.05 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL" 9512694_1 CDM 351 RC 70450 HCPCS outpatient 1499 1124.25 AETNA MCR ADV AETNA MCR ADV 1169.22 78 999999999 1169.22 1424.05 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL" 9512694_1 CDM 351 RC 70450 HCPCS outpatient 1499 1124.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1312.67 87.57 999999999 1169.22 1424.05 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL" 9512694_1 CDM 351 RC 70450 HCPCS outpatient 1499 1124.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 1275.2 85.07 999999999 1169.22 1424.05 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL" 9512694_1 CDM 351 RC 70450 HCPCS outpatient 1499 1124.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1275.2 85.07 999999999 1169.22 1424.05 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL" 9512694_1 CDM 351 RC 70450 HCPCS outpatient 1499 1124.25 MOLINA MCAID MOLINA MCAID 1250.17 83.4 999999999 1169.22 1424.05 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL" 9512694_1 CDM 351 RC 70450 HCPCS outpatient 1499 1124.25 MOLINA MCR ADV MOLINA MCR ADV 1334.11 89 999999999 1169.22 1424.05 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL" 9512694_1 CDM 351 RC 70450 HCPCS outpatient 1499 1124.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1334.11 89 999999999 1169.22 1424.05 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL" 9512694_1 CDM 351 RC 70450 HCPCS outpatient 1499 1124.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1334.11 89 999999999 1169.22 1424.05 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL" 9512694_1 CDM 351 RC 70450 HCPCS outpatient 1499 1124.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1349.1 90 999999999 1169.22 1424.05 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL" 9512694_1 CDM 351 RC 70450 HCPCS outpatient 1499 1124.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1424.05 95 999999999 1169.22 1424.05 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL" 9512694_1 CDM 351 RC 70450 HCPCS outpatient 1499 1124.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1424.05 95 999999999 1169.22 1424.05 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL" 9512694_1 CDM 351 RC 70450 HCPCS outpatient 1499 1124.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1334.11 89 999999999 1169.22 1424.05 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL" 9512694_1 CDM 351 RC 70450 HCPCS outpatient 1499 1124.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1319.12 88 999999999 1169.22 1424.05 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL" 9512694_1 CDM 351 RC 70450 HCPCS outpatient 1499 1124.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1334.11 89 999999999 1169.22 1424.05 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITH CONTRAST MATERIAL(S)" 9512697_1 CDM 351 RC 70460 HCPCS outpatient 1833 1374.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1649.7 90 999999999 1429.74 1741.35 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITH CONTRAST MATERIAL(S)" 9512697_1 CDM 351 RC 70460 HCPCS outpatient 1833 1374.75 AETNA MCR ADV AETNA MCR ADV 1429.74 78 999999999 1429.74 1741.35 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITH CONTRAST MATERIAL(S)" 9512697_1 CDM 351 RC 70460 HCPCS outpatient 1833 1374.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1605.16 87.57 999999999 1429.74 1741.35 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITH CONTRAST MATERIAL(S)" 9512697_1 CDM 351 RC 70460 HCPCS outpatient 1833 1374.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 1559.33 85.07 999999999 1429.74 1741.35 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITH CONTRAST MATERIAL(S)" 9512697_1 CDM 351 RC 70460 HCPCS outpatient 1833 1374.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1559.33 85.07 999999999 1429.74 1741.35 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITH CONTRAST MATERIAL(S)" 9512697_1 CDM 351 RC 70460 HCPCS outpatient 1833 1374.75 MOLINA MCAID MOLINA MCAID 1528.72 83.4 999999999 1429.74 1741.35 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITH CONTRAST MATERIAL(S)" 9512697_1 CDM 351 RC 70460 HCPCS outpatient 1833 1374.75 MOLINA MCR ADV MOLINA MCR ADV 1631.37 89 999999999 1429.74 1741.35 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITH CONTRAST MATERIAL(S)" 9512697_1 CDM 351 RC 70460 HCPCS outpatient 1833 1374.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1631.37 89 999999999 1429.74 1741.35 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITH CONTRAST MATERIAL(S)" 9512697_1 CDM 351 RC 70460 HCPCS outpatient 1833 1374.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1631.37 89 999999999 1429.74 1741.35 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITH CONTRAST MATERIAL(S)" 9512697_1 CDM 351 RC 70460 HCPCS outpatient 1833 1374.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1649.7 90 999999999 1429.74 1741.35 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITH CONTRAST MATERIAL(S)" 9512697_1 CDM 351 RC 70460 HCPCS outpatient 1833 1374.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1741.35 95 999999999 1429.74 1741.35 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITH CONTRAST MATERIAL(S)" 9512697_1 CDM 351 RC 70460 HCPCS outpatient 1833 1374.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1741.35 95 999999999 1429.74 1741.35 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITH CONTRAST MATERIAL(S)" 9512697_1 CDM 351 RC 70460 HCPCS outpatient 1833 1374.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1631.37 89 999999999 1429.74 1741.35 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITH CONTRAST MATERIAL(S)" 9512697_1 CDM 351 RC 70460 HCPCS outpatient 1833 1374.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1613.04 88 999999999 1429.74 1741.35 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITH CONTRAST MATERIAL(S)" 9512697_1 CDM 351 RC 70460 HCPCS outpatient 1833 1374.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1631.37 89 999999999 1429.74 1741.35 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512700_1 CDM 351 RC 70470 HCPCS outpatient 3028 2271 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 2725.2 90 999999999 2361.84 2876.6 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512700_1 CDM 351 RC 70470 HCPCS outpatient 3028 2271 AETNA MCR ADV AETNA MCR ADV 2361.84 78 999999999 2361.84 2876.6 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512700_1 CDM 351 RC 70470 HCPCS outpatient 3028 2271 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 2651.62 87.57 999999999 2361.84 2876.6 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512700_1 CDM 351 RC 70470 HCPCS outpatient 3028 2271 COORDINATED CARE MCAID COORDINATED CARE MCAID 2575.92 85.07 999999999 2361.84 2876.6 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512700_1 CDM 351 RC 70470 HCPCS outpatient 3028 2271 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 2575.92 85.07 999999999 2361.84 2876.6 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512700_1 CDM 351 RC 70470 HCPCS outpatient 3028 2271 MOLINA MCAID MOLINA MCAID 2525.35 83.4 999999999 2361.84 2876.6 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512700_1 CDM 351 RC 70470 HCPCS outpatient 3028 2271 MOLINA MCR ADV MOLINA MCR ADV 2694.92 89 999999999 2361.84 2876.6 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512700_1 CDM 351 RC 70470 HCPCS outpatient 3028 2271 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 2694.92 89 999999999 2361.84 2876.6 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512700_1 CDM 351 RC 70470 HCPCS outpatient 3028 2271 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 2694.92 89 999999999 2361.84 2876.6 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512700_1 CDM 351 RC 70470 HCPCS outpatient 3028 2271 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 2725.2 90 999999999 2361.84 2876.6 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512700_1 CDM 351 RC 70470 HCPCS outpatient 3028 2271 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 2876.6 95 999999999 2361.84 2876.6 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512700_1 CDM 351 RC 70470 HCPCS outpatient 3028 2271 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 2876.6 95 999999999 2361.84 2876.6 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512700_1 CDM 351 RC 70470 HCPCS outpatient 3028 2271 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 2694.92 89 999999999 2361.84 2876.6 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512700_1 CDM 351 RC 70470 HCPCS outpatient 3028 2271 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 2664.64 88 999999999 2361.84 2876.6 percent of total billed charges "COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512700_1 CDM 351 RC 70470 HCPCS outpatient 3028 2271 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 2694.92 89 999999999 2361.84 2876.6 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT CONTRAST MATERIAL" 9512703_1 CDM 351 RC 70480 HCPCS outpatient 1468 1101 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1321.2 90 999999999 1145.04 1394.6 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT CONTRAST MATERIAL" 9512703_1 CDM 351 RC 70480 HCPCS outpatient 1468 1101 AETNA MCR ADV AETNA MCR ADV 1145.04 78 999999999 1145.04 1394.6 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT CONTRAST MATERIAL" 9512703_1 CDM 351 RC 70480 HCPCS outpatient 1468 1101 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1285.53 87.57 999999999 1145.04 1394.6 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT CONTRAST MATERIAL" 9512703_1 CDM 351 RC 70480 HCPCS outpatient 1468 1101 COORDINATED CARE MCAID COORDINATED CARE MCAID 1248.83 85.07 999999999 1145.04 1394.6 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT CONTRAST MATERIAL" 9512703_1 CDM 351 RC 70480 HCPCS outpatient 1468 1101 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1248.83 85.07 999999999 1145.04 1394.6 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT CONTRAST MATERIAL" 9512703_1 CDM 351 RC 70480 HCPCS outpatient 1468 1101 MOLINA MCAID MOLINA MCAID 1224.31 83.4 999999999 1145.04 1394.6 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT CONTRAST MATERIAL" 9512703_1 CDM 351 RC 70480 HCPCS outpatient 1468 1101 MOLINA MCR ADV MOLINA MCR ADV 1306.52 89 999999999 1145.04 1394.6 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT CONTRAST MATERIAL" 9512703_1 CDM 351 RC 70480 HCPCS outpatient 1468 1101 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1306.52 89 999999999 1145.04 1394.6 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT CONTRAST MATERIAL" 9512703_1 CDM 351 RC 70480 HCPCS outpatient 1468 1101 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1306.52 89 999999999 1145.04 1394.6 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT CONTRAST MATERIAL" 9512703_1 CDM 351 RC 70480 HCPCS outpatient 1468 1101 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1321.2 90 999999999 1145.04 1394.6 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT CONTRAST MATERIAL" 9512703_1 CDM 351 RC 70480 HCPCS outpatient 1468 1101 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1394.6 95 999999999 1145.04 1394.6 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT CONTRAST MATERIAL" 9512703_1 CDM 351 RC 70480 HCPCS outpatient 1468 1101 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1394.6 95 999999999 1145.04 1394.6 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT CONTRAST MATERIAL" 9512703_1 CDM 351 RC 70480 HCPCS outpatient 1468 1101 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1306.52 89 999999999 1145.04 1394.6 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT CONTRAST MATERIAL" 9512703_1 CDM 351 RC 70480 HCPCS outpatient 1468 1101 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1291.84 88 999999999 1145.04 1394.6 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT CONTRAST MATERIAL" 9512703_1 CDM 351 RC 70480 HCPCS outpatient 1468 1101 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1306.52 89 999999999 1145.04 1394.6 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITH CONTRAST MATERIAL(S)" 9512706_1 CDM 351 RC 70481 HCPCS outpatient 2050 1537.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1845 90 999999999 1599 1947.5 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITH CONTRAST MATERIAL(S)" 9512706_1 CDM 351 RC 70481 HCPCS outpatient 2050 1537.5 AETNA MCR ADV AETNA MCR ADV 1599 78 999999999 1599 1947.5 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITH CONTRAST MATERIAL(S)" 9512706_1 CDM 351 RC 70481 HCPCS outpatient 2050 1537.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1795.19 87.57 999999999 1599 1947.5 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITH CONTRAST MATERIAL(S)" 9512706_1 CDM 351 RC 70481 HCPCS outpatient 2050 1537.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 1743.94 85.07 999999999 1599 1947.5 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITH CONTRAST MATERIAL(S)" 9512706_1 CDM 351 RC 70481 HCPCS outpatient 2050 1537.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1743.94 85.07 999999999 1599 1947.5 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITH CONTRAST MATERIAL(S)" 9512706_1 CDM 351 RC 70481 HCPCS outpatient 2050 1537.5 MOLINA MCAID MOLINA MCAID 1709.7 83.4 999999999 1599 1947.5 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITH CONTRAST MATERIAL(S)" 9512706_1 CDM 351 RC 70481 HCPCS outpatient 2050 1537.5 MOLINA MCR ADV MOLINA MCR ADV 1824.5 89 999999999 1599 1947.5 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITH CONTRAST MATERIAL(S)" 9512706_1 CDM 351 RC 70481 HCPCS outpatient 2050 1537.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1824.5 89 999999999 1599 1947.5 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITH CONTRAST MATERIAL(S)" 9512706_1 CDM 351 RC 70481 HCPCS outpatient 2050 1537.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1824.5 89 999999999 1599 1947.5 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITH CONTRAST MATERIAL(S)" 9512706_1 CDM 351 RC 70481 HCPCS outpatient 2050 1537.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1845 90 999999999 1599 1947.5 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITH CONTRAST MATERIAL(S)" 9512706_1 CDM 351 RC 70481 HCPCS outpatient 2050 1537.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1947.5 95 999999999 1599 1947.5 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITH CONTRAST MATERIAL(S)" 9512706_1 CDM 351 RC 70481 HCPCS outpatient 2050 1537.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1947.5 95 999999999 1599 1947.5 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITH CONTRAST MATERIAL(S)" 9512706_1 CDM 351 RC 70481 HCPCS outpatient 2050 1537.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1824.5 89 999999999 1599 1947.5 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITH CONTRAST MATERIAL(S)" 9512706_1 CDM 351 RC 70481 HCPCS outpatient 2050 1537.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1804 88 999999999 1599 1947.5 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITH CONTRAST MATERIAL(S)" 9512706_1 CDM 351 RC 70481 HCPCS outpatient 2050 1537.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1824.5 89 999999999 1599 1947.5 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512709_1 CDM 351 RC 70482 HCPCS outpatient 3128 2346 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 2815.2 90 999999999 2439.84 2971.6 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512709_1 CDM 351 RC 70482 HCPCS outpatient 3128 2346 AETNA MCR ADV AETNA MCR ADV 2439.84 78 999999999 2439.84 2971.6 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512709_1 CDM 351 RC 70482 HCPCS outpatient 3128 2346 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 2739.19 87.57 999999999 2439.84 2971.6 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512709_1 CDM 351 RC 70482 HCPCS outpatient 3128 2346 COORDINATED CARE MCAID COORDINATED CARE MCAID 2660.99 85.07 999999999 2439.84 2971.6 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512709_1 CDM 351 RC 70482 HCPCS outpatient 3128 2346 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 2660.99 85.07 999999999 2439.84 2971.6 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512709_1 CDM 351 RC 70482 HCPCS outpatient 3128 2346 MOLINA MCAID MOLINA MCAID 2608.75 83.4 999999999 2439.84 2971.6 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512709_1 CDM 351 RC 70482 HCPCS outpatient 3128 2346 MOLINA MCR ADV MOLINA MCR ADV 2783.92 89 999999999 2439.84 2971.6 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512709_1 CDM 351 RC 70482 HCPCS outpatient 3128 2346 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 2783.92 89 999999999 2439.84 2971.6 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512709_1 CDM 351 RC 70482 HCPCS outpatient 3128 2346 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 2783.92 89 999999999 2439.84 2971.6 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512709_1 CDM 351 RC 70482 HCPCS outpatient 3128 2346 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 2815.2 90 999999999 2439.84 2971.6 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512709_1 CDM 351 RC 70482 HCPCS outpatient 3128 2346 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 2971.6 95 999999999 2439.84 2971.6 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512709_1 CDM 351 RC 70482 HCPCS outpatient 3128 2346 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 2971.6 95 999999999 2439.84 2971.6 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512709_1 CDM 351 RC 70482 HCPCS outpatient 3128 2346 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 2783.92 89 999999999 2439.84 2971.6 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512709_1 CDM 351 RC 70482 HCPCS outpatient 3128 2346 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 2752.64 88 999999999 2439.84 2971.6 percent of total billed charges "COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512709_1 CDM 351 RC 70482 HCPCS outpatient 3128 2346 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 2783.92 89 999999999 2439.84 2971.6 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL" 9512712_1 CDM 351 RC 70486 HCPCS outpatient 1389 1041.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1250.1 90 999999999 1083.42 1319.55 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL" 9512712_1 CDM 351 RC 70486 HCPCS outpatient 1389 1041.75 AETNA MCR ADV AETNA MCR ADV 1083.42 78 999999999 1083.42 1319.55 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL" 9512712_1 CDM 351 RC 70486 HCPCS outpatient 1389 1041.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1216.35 87.57 999999999 1083.42 1319.55 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL" 9512712_1 CDM 351 RC 70486 HCPCS outpatient 1389 1041.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 1181.62 85.07 999999999 1083.42 1319.55 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL" 9512712_1 CDM 351 RC 70486 HCPCS outpatient 1389 1041.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1181.62 85.07 999999999 1083.42 1319.55 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL" 9512712_1 CDM 351 RC 70486 HCPCS outpatient 1389 1041.75 MOLINA MCAID MOLINA MCAID 1158.43 83.4 999999999 1083.42 1319.55 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL" 9512712_1 CDM 351 RC 70486 HCPCS outpatient 1389 1041.75 MOLINA MCR ADV MOLINA MCR ADV 1236.21 89 999999999 1083.42 1319.55 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL" 9512712_1 CDM 351 RC 70486 HCPCS outpatient 1389 1041.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1236.21 89 999999999 1083.42 1319.55 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL" 9512712_1 CDM 351 RC 70486 HCPCS outpatient 1389 1041.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1236.21 89 999999999 1083.42 1319.55 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL" 9512712_1 CDM 351 RC 70486 HCPCS outpatient 1389 1041.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1250.1 90 999999999 1083.42 1319.55 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL" 9512712_1 CDM 351 RC 70486 HCPCS outpatient 1389 1041.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1319.55 95 999999999 1083.42 1319.55 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL" 9512712_1 CDM 351 RC 70486 HCPCS outpatient 1389 1041.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1319.55 95 999999999 1083.42 1319.55 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL" 9512712_1 CDM 351 RC 70486 HCPCS outpatient 1389 1041.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1236.21 89 999999999 1083.42 1319.55 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL" 9512712_1 CDM 351 RC 70486 HCPCS outpatient 1389 1041.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1222.32 88 999999999 1083.42 1319.55 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL" 9512712_1 CDM 351 RC 70486 HCPCS outpatient 1389 1041.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1236.21 89 999999999 1083.42 1319.55 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITH CONTRAST MATERIAL(S)" 9512715_1 CDM 351 RC 70487 HCPCS outpatient 1916 1437 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1724.4 90 999999999 1494.48 1820.2 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITH CONTRAST MATERIAL(S)" 9512715_1 CDM 351 RC 70487 HCPCS outpatient 1916 1437 AETNA MCR ADV AETNA MCR ADV 1494.48 78 999999999 1494.48 1820.2 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITH CONTRAST MATERIAL(S)" 9512715_1 CDM 351 RC 70487 HCPCS outpatient 1916 1437 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1677.84 87.57 999999999 1494.48 1820.2 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITH CONTRAST MATERIAL(S)" 9512715_1 CDM 351 RC 70487 HCPCS outpatient 1916 1437 COORDINATED CARE MCAID COORDINATED CARE MCAID 1629.94 85.07 999999999 1494.48 1820.2 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITH CONTRAST MATERIAL(S)" 9512715_1 CDM 351 RC 70487 HCPCS outpatient 1916 1437 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1629.94 85.07 999999999 1494.48 1820.2 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITH CONTRAST MATERIAL(S)" 9512715_1 CDM 351 RC 70487 HCPCS outpatient 1916 1437 MOLINA MCAID MOLINA MCAID 1597.94 83.4 999999999 1494.48 1820.2 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITH CONTRAST MATERIAL(S)" 9512715_1 CDM 351 RC 70487 HCPCS outpatient 1916 1437 MOLINA MCR ADV MOLINA MCR ADV 1705.24 89 999999999 1494.48 1820.2 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITH CONTRAST MATERIAL(S)" 9512715_1 CDM 351 RC 70487 HCPCS outpatient 1916 1437 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1705.24 89 999999999 1494.48 1820.2 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITH CONTRAST MATERIAL(S)" 9512715_1 CDM 351 RC 70487 HCPCS outpatient 1916 1437 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1705.24 89 999999999 1494.48 1820.2 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITH CONTRAST MATERIAL(S)" 9512715_1 CDM 351 RC 70487 HCPCS outpatient 1916 1437 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1724.4 90 999999999 1494.48 1820.2 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITH CONTRAST MATERIAL(S)" 9512715_1 CDM 351 RC 70487 HCPCS outpatient 1916 1437 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1820.2 95 999999999 1494.48 1820.2 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITH CONTRAST MATERIAL(S)" 9512715_1 CDM 351 RC 70487 HCPCS outpatient 1916 1437 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1820.2 95 999999999 1494.48 1820.2 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITH CONTRAST MATERIAL(S)" 9512715_1 CDM 351 RC 70487 HCPCS outpatient 1916 1437 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1705.24 89 999999999 1494.48 1820.2 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITH CONTRAST MATERIAL(S)" 9512715_1 CDM 351 RC 70487 HCPCS outpatient 1916 1437 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1686.08 88 999999999 1494.48 1820.2 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITH CONTRAST MATERIAL(S)" 9512715_1 CDM 351 RC 70487 HCPCS outpatient 1916 1437 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1705.24 89 999999999 1494.48 1820.2 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512718_1 CDM 351 RC 70488 HCPCS outpatient 2420 1815 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 2178 90 999999999 1887.6 2299 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512718_1 CDM 351 RC 70488 HCPCS outpatient 2420 1815 AETNA MCR ADV AETNA MCR ADV 1887.6 78 999999999 1887.6 2299 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512718_1 CDM 351 RC 70488 HCPCS outpatient 2420 1815 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 2119.19 87.57 999999999 1887.6 2299 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512718_1 CDM 351 RC 70488 HCPCS outpatient 2420 1815 COORDINATED CARE MCAID COORDINATED CARE MCAID 2058.69 85.07 999999999 1887.6 2299 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512718_1 CDM 351 RC 70488 HCPCS outpatient 2420 1815 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 2058.69 85.07 999999999 1887.6 2299 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512718_1 CDM 351 RC 70488 HCPCS outpatient 2420 1815 MOLINA MCAID MOLINA MCAID 2018.28 83.4 999999999 1887.6 2299 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512718_1 CDM 351 RC 70488 HCPCS outpatient 2420 1815 MOLINA MCR ADV MOLINA MCR ADV 2153.8 89 999999999 1887.6 2299 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512718_1 CDM 351 RC 70488 HCPCS outpatient 2420 1815 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 2153.8 89 999999999 1887.6 2299 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512718_1 CDM 351 RC 70488 HCPCS outpatient 2420 1815 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 2153.8 89 999999999 1887.6 2299 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512718_1 CDM 351 RC 70488 HCPCS outpatient 2420 1815 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 2178 90 999999999 1887.6 2299 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512718_1 CDM 351 RC 70488 HCPCS outpatient 2420 1815 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 2299 95 999999999 1887.6 2299 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512718_1 CDM 351 RC 70488 HCPCS outpatient 2420 1815 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 2299 95 999999999 1887.6 2299 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512718_1 CDM 351 RC 70488 HCPCS outpatient 2420 1815 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 2153.8 89 999999999 1887.6 2299 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512718_1 CDM 351 RC 70488 HCPCS outpatient 2420 1815 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 2129.6 88 999999999 1887.6 2299 percent of total billed charges "COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512718_1 CDM 351 RC 70488 HCPCS outpatient 2420 1815 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 2153.8 89 999999999 1887.6 2299 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL" 9512721_1 CDM 351 RC 70490 HCPCS outpatient 1390 1042.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1251 90 999999999 1084.2 1320.5 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL" 9512721_1 CDM 351 RC 70490 HCPCS outpatient 1390 1042.5 AETNA MCR ADV AETNA MCR ADV 1084.2 78 999999999 1084.2 1320.5 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL" 9512721_1 CDM 351 RC 70490 HCPCS outpatient 1390 1042.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1217.22 87.57 999999999 1084.2 1320.5 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL" 9512721_1 CDM 351 RC 70490 HCPCS outpatient 1390 1042.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 1182.47 85.07 999999999 1084.2 1320.5 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL" 9512721_1 CDM 351 RC 70490 HCPCS outpatient 1390 1042.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1182.47 85.07 999999999 1084.2 1320.5 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL" 9512721_1 CDM 351 RC 70490 HCPCS outpatient 1390 1042.5 MOLINA MCAID MOLINA MCAID 1159.26 83.4 999999999 1084.2 1320.5 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL" 9512721_1 CDM 351 RC 70490 HCPCS outpatient 1390 1042.5 MOLINA MCR ADV MOLINA MCR ADV 1237.1 89 999999999 1084.2 1320.5 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL" 9512721_1 CDM 351 RC 70490 HCPCS outpatient 1390 1042.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1237.1 89 999999999 1084.2 1320.5 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL" 9512721_1 CDM 351 RC 70490 HCPCS outpatient 1390 1042.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1237.1 89 999999999 1084.2 1320.5 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL" 9512721_1 CDM 351 RC 70490 HCPCS outpatient 1390 1042.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1251 90 999999999 1084.2 1320.5 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL" 9512721_1 CDM 351 RC 70490 HCPCS outpatient 1390 1042.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1320.5 95 999999999 1084.2 1320.5 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL" 9512721_1 CDM 351 RC 70490 HCPCS outpatient 1390 1042.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1320.5 95 999999999 1084.2 1320.5 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL" 9512721_1 CDM 351 RC 70490 HCPCS outpatient 1390 1042.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1237.1 89 999999999 1084.2 1320.5 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL" 9512721_1 CDM 351 RC 70490 HCPCS outpatient 1390 1042.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1223.2 88 999999999 1084.2 1320.5 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL" 9512721_1 CDM 351 RC 70490 HCPCS outpatient 1390 1042.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1237.1 89 999999999 1084.2 1320.5 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITH CONTRAST MATERIAL(S)" 9512724_1 CDM 351 RC 70491 HCPCS outpatient 1980 1485 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1782 90 999999999 1544.4 1881 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITH CONTRAST MATERIAL(S)" 9512724_1 CDM 351 RC 70491 HCPCS outpatient 1980 1485 AETNA MCR ADV AETNA MCR ADV 1544.4 78 999999999 1544.4 1881 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITH CONTRAST MATERIAL(S)" 9512724_1 CDM 351 RC 70491 HCPCS outpatient 1980 1485 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1733.89 87.57 999999999 1544.4 1881 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITH CONTRAST MATERIAL(S)" 9512724_1 CDM 351 RC 70491 HCPCS outpatient 1980 1485 COORDINATED CARE MCAID COORDINATED CARE MCAID 1684.39 85.07 999999999 1544.4 1881 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITH CONTRAST MATERIAL(S)" 9512724_1 CDM 351 RC 70491 HCPCS outpatient 1980 1485 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1684.39 85.07 999999999 1544.4 1881 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITH CONTRAST MATERIAL(S)" 9512724_1 CDM 351 RC 70491 HCPCS outpatient 1980 1485 MOLINA MCAID MOLINA MCAID 1651.32 83.4 999999999 1544.4 1881 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITH CONTRAST MATERIAL(S)" 9512724_1 CDM 351 RC 70491 HCPCS outpatient 1980 1485 MOLINA MCR ADV MOLINA MCR ADV 1762.2 89 999999999 1544.4 1881 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITH CONTRAST MATERIAL(S)" 9512724_1 CDM 351 RC 70491 HCPCS outpatient 1980 1485 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1762.2 89 999999999 1544.4 1881 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITH CONTRAST MATERIAL(S)" 9512724_1 CDM 351 RC 70491 HCPCS outpatient 1980 1485 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1762.2 89 999999999 1544.4 1881 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITH CONTRAST MATERIAL(S)" 9512724_1 CDM 351 RC 70491 HCPCS outpatient 1980 1485 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1782 90 999999999 1544.4 1881 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITH CONTRAST MATERIAL(S)" 9512724_1 CDM 351 RC 70491 HCPCS outpatient 1980 1485 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1881 95 999999999 1544.4 1881 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITH CONTRAST MATERIAL(S)" 9512724_1 CDM 351 RC 70491 HCPCS outpatient 1980 1485 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1881 95 999999999 1544.4 1881 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITH CONTRAST MATERIAL(S)" 9512724_1 CDM 351 RC 70491 HCPCS outpatient 1980 1485 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1762.2 89 999999999 1544.4 1881 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITH CONTRAST MATERIAL(S)" 9512724_1 CDM 351 RC 70491 HCPCS outpatient 1980 1485 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1742.4 88 999999999 1544.4 1881 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITH CONTRAST MATERIAL(S)" 9512724_1 CDM 351 RC 70491 HCPCS outpatient 1980 1485 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1762.2 89 999999999 1544.4 1881 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512727_1 CDM 351 RC 70492 HCPCS outpatient 2250 1687.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 2025 90 999999999 1755 2137.5 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512727_1 CDM 351 RC 70492 HCPCS outpatient 2250 1687.5 AETNA MCR ADV AETNA MCR ADV 1755 78 999999999 1755 2137.5 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512727_1 CDM 351 RC 70492 HCPCS outpatient 2250 1687.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1970.33 87.57 999999999 1755 2137.5 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512727_1 CDM 351 RC 70492 HCPCS outpatient 2250 1687.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 1914.08 85.07 999999999 1755 2137.5 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512727_1 CDM 351 RC 70492 HCPCS outpatient 2250 1687.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1914.08 85.07 999999999 1755 2137.5 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512727_1 CDM 351 RC 70492 HCPCS outpatient 2250 1687.5 MOLINA MCAID MOLINA MCAID 1876.5 83.4 999999999 1755 2137.5 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512727_1 CDM 351 RC 70492 HCPCS outpatient 2250 1687.5 MOLINA MCR ADV MOLINA MCR ADV 2002.5 89 999999999 1755 2137.5 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512727_1 CDM 351 RC 70492 HCPCS outpatient 2250 1687.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 2002.5 89 999999999 1755 2137.5 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512727_1 CDM 351 RC 70492 HCPCS outpatient 2250 1687.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 2002.5 89 999999999 1755 2137.5 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512727_1 CDM 351 RC 70492 HCPCS outpatient 2250 1687.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 2025 90 999999999 1755 2137.5 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512727_1 CDM 351 RC 70492 HCPCS outpatient 2250 1687.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 2137.5 95 999999999 1755 2137.5 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512727_1 CDM 351 RC 70492 HCPCS outpatient 2250 1687.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 2137.5 95 999999999 1755 2137.5 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512727_1 CDM 351 RC 70492 HCPCS outpatient 2250 1687.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 2002.5 89 999999999 1755 2137.5 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512727_1 CDM 351 RC 70492 HCPCS outpatient 2250 1687.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1980 88 999999999 1755 2137.5 percent of total billed charges "COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512727_1 CDM 351 RC 70492 HCPCS outpatient 2250 1687.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 2002.5 89 999999999 1755 2137.5 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, HEAD, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512730_1 CDM 351 RC 70496 HCPCS outpatient 2346 1759.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 2111.4 90 999999999 1829.88 2228.7 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, HEAD, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512730_1 CDM 351 RC 70496 HCPCS outpatient 2346 1759.5 AETNA MCR ADV AETNA MCR ADV 1829.88 78 999999999 1829.88 2228.7 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, HEAD, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512730_1 CDM 351 RC 70496 HCPCS outpatient 2346 1759.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 2054.39 87.57 999999999 1829.88 2228.7 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, HEAD, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512730_1 CDM 351 RC 70496 HCPCS outpatient 2346 1759.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 1995.74 85.07 999999999 1829.88 2228.7 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, HEAD, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512730_1 CDM 351 RC 70496 HCPCS outpatient 2346 1759.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1995.74 85.07 999999999 1829.88 2228.7 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, HEAD, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512730_1 CDM 351 RC 70496 HCPCS outpatient 2346 1759.5 MOLINA MCAID MOLINA MCAID 1956.56 83.4 999999999 1829.88 2228.7 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, HEAD, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512730_1 CDM 351 RC 70496 HCPCS outpatient 2346 1759.5 MOLINA MCR ADV MOLINA MCR ADV 2087.94 89 999999999 1829.88 2228.7 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, HEAD, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512730_1 CDM 351 RC 70496 HCPCS outpatient 2346 1759.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 2087.94 89 999999999 1829.88 2228.7 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, HEAD, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512730_1 CDM 351 RC 70496 HCPCS outpatient 2346 1759.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 2087.94 89 999999999 1829.88 2228.7 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, HEAD, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512730_1 CDM 351 RC 70496 HCPCS outpatient 2346 1759.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 2111.4 90 999999999 1829.88 2228.7 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, HEAD, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512730_1 CDM 351 RC 70496 HCPCS outpatient 2346 1759.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 2228.7 95 999999999 1829.88 2228.7 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, HEAD, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512730_1 CDM 351 RC 70496 HCPCS outpatient 2346 1759.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 2228.7 95 999999999 1829.88 2228.7 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, HEAD, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512730_1 CDM 351 RC 70496 HCPCS outpatient 2346 1759.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 2087.94 89 999999999 1829.88 2228.7 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, HEAD, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512730_1 CDM 351 RC 70496 HCPCS outpatient 2346 1759.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 2064.48 88 999999999 1829.88 2228.7 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, HEAD, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512730_1 CDM 351 RC 70496 HCPCS outpatient 2346 1759.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 2087.94 89 999999999 1829.88 2228.7 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, NECK, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512733_1 CDM 351 RC 70498 HCPCS outpatient 2545 1908.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 2290.5 90 999999999 1985.1 2417.75 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, NECK, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512733_1 CDM 351 RC 70498 HCPCS outpatient 2545 1908.75 AETNA MCR ADV AETNA MCR ADV 1985.1 78 999999999 1985.1 2417.75 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, NECK, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512733_1 CDM 351 RC 70498 HCPCS outpatient 2545 1908.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 2228.66 87.57 999999999 1985.1 2417.75 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, NECK, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512733_1 CDM 351 RC 70498 HCPCS outpatient 2545 1908.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 2165.03 85.07 999999999 1985.1 2417.75 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, NECK, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512733_1 CDM 351 RC 70498 HCPCS outpatient 2545 1908.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 2165.03 85.07 999999999 1985.1 2417.75 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, NECK, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512733_1 CDM 351 RC 70498 HCPCS outpatient 2545 1908.75 MOLINA MCAID MOLINA MCAID 2122.53 83.4 999999999 1985.1 2417.75 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, NECK, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512733_1 CDM 351 RC 70498 HCPCS outpatient 2545 1908.75 MOLINA MCR ADV MOLINA MCR ADV 2265.05 89 999999999 1985.1 2417.75 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, NECK, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512733_1 CDM 351 RC 70498 HCPCS outpatient 2545 1908.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 2265.05 89 999999999 1985.1 2417.75 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, NECK, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512733_1 CDM 351 RC 70498 HCPCS outpatient 2545 1908.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 2265.05 89 999999999 1985.1 2417.75 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, NECK, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512733_1 CDM 351 RC 70498 HCPCS outpatient 2545 1908.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 2290.5 90 999999999 1985.1 2417.75 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, NECK, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512733_1 CDM 351 RC 70498 HCPCS outpatient 2545 1908.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 2417.75 95 999999999 1985.1 2417.75 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, NECK, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512733_1 CDM 351 RC 70498 HCPCS outpatient 2545 1908.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 2417.75 95 999999999 1985.1 2417.75 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, NECK, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512733_1 CDM 351 RC 70498 HCPCS outpatient 2545 1908.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 2265.05 89 999999999 1985.1 2417.75 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, NECK, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512733_1 CDM 351 RC 70498 HCPCS outpatient 2545 1908.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 2239.6 88 999999999 1985.1 2417.75 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, NECK, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512733_1 CDM 351 RC 70498 HCPCS outpatient 2545 1908.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 2265.05 89 999999999 1985.1 2417.75 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITHOUT CONTRAST MATERIAL(S)" 9512736_1 CDM 611 RC 70540 HCPCS outpatient 2472 1854 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 2224.8 90 999999999 1928.16 2348.4 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITHOUT CONTRAST MATERIAL(S)" 9512736_1 CDM 611 RC 70540 HCPCS outpatient 2472 1854 AETNA MCR ADV AETNA MCR ADV 1928.16 78 999999999 1928.16 2348.4 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITHOUT CONTRAST MATERIAL(S)" 9512736_1 CDM 611 RC 70540 HCPCS outpatient 2472 1854 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 2164.73 87.57 999999999 1928.16 2348.4 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITHOUT CONTRAST MATERIAL(S)" 9512736_1 CDM 611 RC 70540 HCPCS outpatient 2472 1854 COORDINATED CARE MCAID COORDINATED CARE MCAID 2102.93 85.07 999999999 1928.16 2348.4 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITHOUT CONTRAST MATERIAL(S)" 9512736_1 CDM 611 RC 70540 HCPCS outpatient 2472 1854 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 2102.93 85.07 999999999 1928.16 2348.4 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITHOUT CONTRAST MATERIAL(S)" 9512736_1 CDM 611 RC 70540 HCPCS outpatient 2472 1854 MOLINA MCAID MOLINA MCAID 2061.65 83.4 999999999 1928.16 2348.4 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITHOUT CONTRAST MATERIAL(S)" 9512736_1 CDM 611 RC 70540 HCPCS outpatient 2472 1854 MOLINA MCR ADV MOLINA MCR ADV 2200.08 89 999999999 1928.16 2348.4 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITHOUT CONTRAST MATERIAL(S)" 9512736_1 CDM 611 RC 70540 HCPCS outpatient 2472 1854 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 2200.08 89 999999999 1928.16 2348.4 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITHOUT CONTRAST MATERIAL(S)" 9512736_1 CDM 611 RC 70540 HCPCS outpatient 2472 1854 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 2200.08 89 999999999 1928.16 2348.4 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITHOUT CONTRAST MATERIAL(S)" 9512736_1 CDM 611 RC 70540 HCPCS outpatient 2472 1854 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 2224.8 90 999999999 1928.16 2348.4 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITHOUT CONTRAST MATERIAL(S)" 9512736_1 CDM 611 RC 70540 HCPCS outpatient 2472 1854 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 2348.4 95 999999999 1928.16 2348.4 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITHOUT CONTRAST MATERIAL(S)" 9512736_1 CDM 611 RC 70540 HCPCS outpatient 2472 1854 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 2348.4 95 999999999 1928.16 2348.4 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITHOUT CONTRAST MATERIAL(S)" 9512736_1 CDM 611 RC 70540 HCPCS outpatient 2472 1854 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 2200.08 89 999999999 1928.16 2348.4 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITHOUT CONTRAST MATERIAL(S)" 9512736_1 CDM 611 RC 70540 HCPCS outpatient 2472 1854 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 2175.36 88 999999999 1928.16 2348.4 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITHOUT CONTRAST MATERIAL(S)" 9512736_1 CDM 611 RC 70540 HCPCS outpatient 2472 1854 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 2200.08 89 999999999 1928.16 2348.4 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512742_1 CDM 611 RC 70543 HCPCS outpatient 3256 2442 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 2930.4 90 999999999 2539.68 3093.2 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512742_1 CDM 611 RC 70543 HCPCS outpatient 3256 2442 AETNA MCR ADV AETNA MCR ADV 2539.68 78 999999999 2539.68 3093.2 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512742_1 CDM 611 RC 70543 HCPCS outpatient 3256 2442 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 2851.28 87.57 999999999 2539.68 3093.2 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512742_1 CDM 611 RC 70543 HCPCS outpatient 3256 2442 COORDINATED CARE MCAID COORDINATED CARE MCAID 2769.88 85.07 999999999 2539.68 3093.2 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512742_1 CDM 611 RC 70543 HCPCS outpatient 3256 2442 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 2769.88 85.07 999999999 2539.68 3093.2 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512742_1 CDM 611 RC 70543 HCPCS outpatient 3256 2442 MOLINA MCAID MOLINA MCAID 2715.5 83.4 999999999 2539.68 3093.2 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512742_1 CDM 611 RC 70543 HCPCS outpatient 3256 2442 MOLINA MCR ADV MOLINA MCR ADV 2897.84 89 999999999 2539.68 3093.2 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512742_1 CDM 611 RC 70543 HCPCS outpatient 3256 2442 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 2897.84 89 999999999 2539.68 3093.2 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512742_1 CDM 611 RC 70543 HCPCS outpatient 3256 2442 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 2897.84 89 999999999 2539.68 3093.2 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512742_1 CDM 611 RC 70543 HCPCS outpatient 3256 2442 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 2930.4 90 999999999 2539.68 3093.2 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512742_1 CDM 611 RC 70543 HCPCS outpatient 3256 2442 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 3093.2 95 999999999 2539.68 3093.2 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512742_1 CDM 611 RC 70543 HCPCS outpatient 3256 2442 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 3093.2 95 999999999 2539.68 3093.2 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512742_1 CDM 611 RC 70543 HCPCS outpatient 3256 2442 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 2897.84 89 999999999 2539.68 3093.2 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512742_1 CDM 611 RC 70543 HCPCS outpatient 3256 2442 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 2865.28 88 999999999 2539.68 3093.2 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512742_1 CDM 611 RC 70543 HCPCS outpatient 3256 2442 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 2897.84 89 999999999 2539.68 3093.2 percent of total billed charges "MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512751_1 CDM 615 RC 70546 HCPCS outpatient 3803 2852.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 3422.7 90 999999999 2966.34 3612.85 percent of total billed charges "MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512751_1 CDM 615 RC 70546 HCPCS outpatient 3803 2852.25 AETNA MCR ADV AETNA MCR ADV 2966.34 78 999999999 2966.34 3612.85 percent of total billed charges "MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512751_1 CDM 615 RC 70546 HCPCS outpatient 3803 2852.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 3330.29 87.57 999999999 2966.34 3612.85 percent of total billed charges "MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512751_1 CDM 615 RC 70546 HCPCS outpatient 3803 2852.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 3235.21 85.07 999999999 2966.34 3612.85 percent of total billed charges "MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512751_1 CDM 615 RC 70546 HCPCS outpatient 3803 2852.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 3235.21 85.07 999999999 2966.34 3612.85 percent of total billed charges "MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512751_1 CDM 615 RC 70546 HCPCS outpatient 3803 2852.25 MOLINA MCAID MOLINA MCAID 3171.7 83.4 999999999 2966.34 3612.85 percent of total billed charges "MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512751_1 CDM 615 RC 70546 HCPCS outpatient 3803 2852.25 MOLINA MCR ADV MOLINA MCR ADV 3384.67 89 999999999 2966.34 3612.85 percent of total billed charges "MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512751_1 CDM 615 RC 70546 HCPCS outpatient 3803 2852.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 3384.67 89 999999999 2966.34 3612.85 percent of total billed charges "MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512751_1 CDM 615 RC 70546 HCPCS outpatient 3803 2852.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 3384.67 89 999999999 2966.34 3612.85 percent of total billed charges "MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512751_1 CDM 615 RC 70546 HCPCS outpatient 3803 2852.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 3422.7 90 999999999 2966.34 3612.85 percent of total billed charges "MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512751_1 CDM 615 RC 70546 HCPCS outpatient 3803 2852.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 3612.85 95 999999999 2966.34 3612.85 percent of total billed charges "MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512751_1 CDM 615 RC 70546 HCPCS outpatient 3803 2852.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 3612.85 95 999999999 2966.34 3612.85 percent of total billed charges "MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512751_1 CDM 615 RC 70546 HCPCS outpatient 3803 2852.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 3384.67 89 999999999 2966.34 3612.85 percent of total billed charges "MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512751_1 CDM 615 RC 70546 HCPCS outpatient 3803 2852.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 3346.64 88 999999999 2966.34 3612.85 percent of total billed charges "MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512751_1 CDM 615 RC 70546 HCPCS outpatient 3803 2852.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 3384.67 89 999999999 2966.34 3612.85 percent of total billed charges "MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512760_1 CDM 615 RC 70549 HCPCS outpatient 3589 2691.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 3230.1 90 999999999 2799.42 3409.55 percent of total billed charges "MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512760_1 CDM 615 RC 70549 HCPCS outpatient 3589 2691.75 AETNA MCR ADV AETNA MCR ADV 2799.42 78 999999999 2799.42 3409.55 percent of total billed charges "MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512760_1 CDM 615 RC 70549 HCPCS outpatient 3589 2691.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 3142.89 87.57 999999999 2799.42 3409.55 percent of total billed charges "MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512760_1 CDM 615 RC 70549 HCPCS outpatient 3589 2691.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 3053.16 85.07 999999999 2799.42 3409.55 percent of total billed charges "MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512760_1 CDM 615 RC 70549 HCPCS outpatient 3589 2691.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 3053.16 85.07 999999999 2799.42 3409.55 percent of total billed charges "MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512760_1 CDM 615 RC 70549 HCPCS outpatient 3589 2691.75 MOLINA MCAID MOLINA MCAID 2993.23 83.4 999999999 2799.42 3409.55 percent of total billed charges "MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512760_1 CDM 615 RC 70549 HCPCS outpatient 3589 2691.75 MOLINA MCR ADV MOLINA MCR ADV 3194.21 89 999999999 2799.42 3409.55 percent of total billed charges "MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512760_1 CDM 615 RC 70549 HCPCS outpatient 3589 2691.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 3194.21 89 999999999 2799.42 3409.55 percent of total billed charges "MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512760_1 CDM 615 RC 70549 HCPCS outpatient 3589 2691.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 3194.21 89 999999999 2799.42 3409.55 percent of total billed charges "MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512760_1 CDM 615 RC 70549 HCPCS outpatient 3589 2691.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 3230.1 90 999999999 2799.42 3409.55 percent of total billed charges "MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512760_1 CDM 615 RC 70549 HCPCS outpatient 3589 2691.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 3409.55 95 999999999 2799.42 3409.55 percent of total billed charges "MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512760_1 CDM 615 RC 70549 HCPCS outpatient 3589 2691.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 3409.55 95 999999999 2799.42 3409.55 percent of total billed charges "MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512760_1 CDM 615 RC 70549 HCPCS outpatient 3589 2691.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 3194.21 89 999999999 2799.42 3409.55 percent of total billed charges "MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512760_1 CDM 615 RC 70549 HCPCS outpatient 3589 2691.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 3158.32 88 999999999 2799.42 3409.55 percent of total billed charges "MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512760_1 CDM 615 RC 70549 HCPCS outpatient 3589 2691.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 3194.21 89 999999999 2799.42 3409.55 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL" 9512763_1 CDM 611 RC 70551 HCPCS outpatient 2335 1751.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 2101.5 90 999999999 1821.3 2218.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL" 9512763_1 CDM 611 RC 70551 HCPCS outpatient 2335 1751.25 AETNA MCR ADV AETNA MCR ADV 1821.3 78 999999999 1821.3 2218.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL" 9512763_1 CDM 611 RC 70551 HCPCS outpatient 2335 1751.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 2044.76 87.57 999999999 1821.3 2218.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL" 9512763_1 CDM 611 RC 70551 HCPCS outpatient 2335 1751.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 1986.38 85.07 999999999 1821.3 2218.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL" 9512763_1 CDM 611 RC 70551 HCPCS outpatient 2335 1751.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1986.38 85.07 999999999 1821.3 2218.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL" 9512763_1 CDM 611 RC 70551 HCPCS outpatient 2335 1751.25 MOLINA MCAID MOLINA MCAID 1947.39 83.4 999999999 1821.3 2218.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL" 9512763_1 CDM 611 RC 70551 HCPCS outpatient 2335 1751.25 MOLINA MCR ADV MOLINA MCR ADV 2078.15 89 999999999 1821.3 2218.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL" 9512763_1 CDM 611 RC 70551 HCPCS outpatient 2335 1751.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 2078.15 89 999999999 1821.3 2218.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL" 9512763_1 CDM 611 RC 70551 HCPCS outpatient 2335 1751.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 2078.15 89 999999999 1821.3 2218.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL" 9512763_1 CDM 611 RC 70551 HCPCS outpatient 2335 1751.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 2101.5 90 999999999 1821.3 2218.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL" 9512763_1 CDM 611 RC 70551 HCPCS outpatient 2335 1751.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 2218.25 95 999999999 1821.3 2218.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL" 9512763_1 CDM 611 RC 70551 HCPCS outpatient 2335 1751.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 2218.25 95 999999999 1821.3 2218.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL" 9512763_1 CDM 611 RC 70551 HCPCS outpatient 2335 1751.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 2078.15 89 999999999 1821.3 2218.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL" 9512763_1 CDM 611 RC 70551 HCPCS outpatient 2335 1751.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 2054.8 88 999999999 1821.3 2218.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL" 9512763_1 CDM 611 RC 70551 HCPCS outpatient 2335 1751.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 2078.15 89 999999999 1821.3 2218.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512770_1 CDM 611 RC 70553 HCPCS outpatient 3728 2796 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 3355.2 90 999999999 2907.84 3541.6 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512770_1 CDM 611 RC 70553 HCPCS outpatient 3728 2796 AETNA MCR ADV AETNA MCR ADV 2907.84 78 999999999 2907.84 3541.6 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512770_1 CDM 611 RC 70553 HCPCS outpatient 3728 2796 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 3264.61 87.57 999999999 2907.84 3541.6 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512770_1 CDM 611 RC 70553 HCPCS outpatient 3728 2796 COORDINATED CARE MCAID COORDINATED CARE MCAID 3171.41 85.07 999999999 2907.84 3541.6 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512770_1 CDM 611 RC 70553 HCPCS outpatient 3728 2796 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 3171.41 85.07 999999999 2907.84 3541.6 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512770_1 CDM 611 RC 70553 HCPCS outpatient 3728 2796 MOLINA MCAID MOLINA MCAID 3109.15 83.4 999999999 2907.84 3541.6 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512770_1 CDM 611 RC 70553 HCPCS outpatient 3728 2796 MOLINA MCR ADV MOLINA MCR ADV 3317.92 89 999999999 2907.84 3541.6 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512770_1 CDM 611 RC 70553 HCPCS outpatient 3728 2796 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 3317.92 89 999999999 2907.84 3541.6 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512770_1 CDM 611 RC 70553 HCPCS outpatient 3728 2796 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 3317.92 89 999999999 2907.84 3541.6 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512770_1 CDM 611 RC 70553 HCPCS outpatient 3728 2796 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 3355.2 90 999999999 2907.84 3541.6 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512770_1 CDM 611 RC 70553 HCPCS outpatient 3728 2796 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 3541.6 95 999999999 2907.84 3541.6 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512770_1 CDM 611 RC 70553 HCPCS outpatient 3728 2796 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 3541.6 95 999999999 2907.84 3541.6 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512770_1 CDM 611 RC 70553 HCPCS outpatient 3728 2796 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 3317.92 89 999999999 2907.84 3541.6 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512770_1 CDM 611 RC 70553 HCPCS outpatient 3728 2796 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 3280.64 88 999999999 2907.84 3541.6 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512770_1 CDM 611 RC 70553 HCPCS outpatient 3728 2796 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 3317.92 89 999999999 2907.84 3541.6 percent of total billed charges "RADIOLOGIC EXAMINATION, RIBS, UNILATERAL; 2 VIEWS" 9512800_1 CDM 320 RC 71100 HCPCS outpatient 343 257.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 308.7 90 999999999 267.54 325.85 percent of total billed charges "RADIOLOGIC EXAMINATION, RIBS, UNILATERAL; 2 VIEWS" 9512800_1 CDM 320 RC 71100 HCPCS outpatient 343 257.25 AETNA MCR ADV AETNA MCR ADV 267.54 78 999999999 267.54 325.85 percent of total billed charges "RADIOLOGIC EXAMINATION, RIBS, UNILATERAL; 2 VIEWS" 9512800_1 CDM 320 RC 71100 HCPCS outpatient 343 257.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 300.37 87.57 999999999 267.54 325.85 percent of total billed charges "RADIOLOGIC EXAMINATION, RIBS, UNILATERAL; 2 VIEWS" 9512800_1 CDM 320 RC 71100 HCPCS outpatient 343 257.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 291.79 85.07 999999999 267.54 325.85 percent of total billed charges "RADIOLOGIC EXAMINATION, RIBS, UNILATERAL; 2 VIEWS" 9512800_1 CDM 320 RC 71100 HCPCS outpatient 343 257.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 291.79 85.07 999999999 267.54 325.85 percent of total billed charges "RADIOLOGIC EXAMINATION, RIBS, UNILATERAL; 2 VIEWS" 9512800_1 CDM 320 RC 71100 HCPCS outpatient 343 257.25 MOLINA MCAID MOLINA MCAID 286.06 83.4 999999999 267.54 325.85 percent of total billed charges "RADIOLOGIC EXAMINATION, RIBS, UNILATERAL; 2 VIEWS" 9512800_1 CDM 320 RC 71100 HCPCS outpatient 343 257.25 MOLINA MCR ADV MOLINA MCR ADV 305.27 89 999999999 267.54 325.85 percent of total billed charges "RADIOLOGIC EXAMINATION, RIBS, UNILATERAL; 2 VIEWS" 9512800_1 CDM 320 RC 71100 HCPCS outpatient 343 257.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 305.27 89 999999999 267.54 325.85 percent of total billed charges "RADIOLOGIC EXAMINATION, RIBS, UNILATERAL; 2 VIEWS" 9512800_1 CDM 320 RC 71100 HCPCS outpatient 343 257.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 305.27 89 999999999 267.54 325.85 percent of total billed charges "RADIOLOGIC EXAMINATION, RIBS, UNILATERAL; 2 VIEWS" 9512800_1 CDM 320 RC 71100 HCPCS outpatient 343 257.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 308.7 90 999999999 267.54 325.85 percent of total billed charges "RADIOLOGIC EXAMINATION, RIBS, UNILATERAL; 2 VIEWS" 9512800_1 CDM 320 RC 71100 HCPCS outpatient 343 257.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 325.85 95 999999999 267.54 325.85 percent of total billed charges "RADIOLOGIC EXAMINATION, RIBS, UNILATERAL; 2 VIEWS" 9512800_1 CDM 320 RC 71100 HCPCS outpatient 343 257.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 325.85 95 999999999 267.54 325.85 percent of total billed charges "RADIOLOGIC EXAMINATION, RIBS, UNILATERAL; 2 VIEWS" 9512800_1 CDM 320 RC 71100 HCPCS outpatient 343 257.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 305.27 89 999999999 267.54 325.85 percent of total billed charges "RADIOLOGIC EXAMINATION, RIBS, UNILATERAL; 2 VIEWS" 9512800_1 CDM 320 RC 71100 HCPCS outpatient 343 257.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 301.84 88 999999999 267.54 325.85 percent of total billed charges "RADIOLOGIC EXAMINATION, RIBS, UNILATERAL; 2 VIEWS" 9512800_1 CDM 320 RC 71100 HCPCS outpatient 343 257.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 305.27 89 999999999 267.54 325.85 percent of total billed charges "RADIOLOGIC EXAMINATION, RIBS, BILATERAL; 3 VIEWS" 9512806_1 CDM 320 RC 71110 HCPCS outpatient 498 373.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 448.2 90 999999999 388.44 473.1 percent of total billed charges "RADIOLOGIC EXAMINATION, RIBS, BILATERAL; 3 VIEWS" 9512806_1 CDM 320 RC 71110 HCPCS outpatient 498 373.5 AETNA MCR ADV AETNA MCR ADV 388.44 78 999999999 388.44 473.1 percent of total billed charges "RADIOLOGIC EXAMINATION, RIBS, BILATERAL; 3 VIEWS" 9512806_1 CDM 320 RC 71110 HCPCS outpatient 498 373.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 436.1 87.57 999999999 388.44 473.1 percent of total billed charges "RADIOLOGIC EXAMINATION, RIBS, BILATERAL; 3 VIEWS" 9512806_1 CDM 320 RC 71110 HCPCS outpatient 498 373.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 423.65 85.07 999999999 388.44 473.1 percent of total billed charges "RADIOLOGIC EXAMINATION, RIBS, BILATERAL; 3 VIEWS" 9512806_1 CDM 320 RC 71110 HCPCS outpatient 498 373.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 423.65 85.07 999999999 388.44 473.1 percent of total billed charges "RADIOLOGIC EXAMINATION, RIBS, BILATERAL; 3 VIEWS" 9512806_1 CDM 320 RC 71110 HCPCS outpatient 498 373.5 MOLINA MCAID MOLINA MCAID 415.33 83.4 999999999 388.44 473.1 percent of total billed charges "RADIOLOGIC EXAMINATION, RIBS, BILATERAL; 3 VIEWS" 9512806_1 CDM 320 RC 71110 HCPCS outpatient 498 373.5 MOLINA MCR ADV MOLINA MCR ADV 443.22 89 999999999 388.44 473.1 percent of total billed charges "RADIOLOGIC EXAMINATION, RIBS, BILATERAL; 3 VIEWS" 9512806_1 CDM 320 RC 71110 HCPCS outpatient 498 373.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 443.22 89 999999999 388.44 473.1 percent of total billed charges "RADIOLOGIC EXAMINATION, RIBS, BILATERAL; 3 VIEWS" 9512806_1 CDM 320 RC 71110 HCPCS outpatient 498 373.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 443.22 89 999999999 388.44 473.1 percent of total billed charges "RADIOLOGIC EXAMINATION, RIBS, BILATERAL; 3 VIEWS" 9512806_1 CDM 320 RC 71110 HCPCS outpatient 498 373.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 448.2 90 999999999 388.44 473.1 percent of total billed charges "RADIOLOGIC EXAMINATION, RIBS, BILATERAL; 3 VIEWS" 9512806_1 CDM 320 RC 71110 HCPCS outpatient 498 373.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 473.1 95 999999999 388.44 473.1 percent of total billed charges "RADIOLOGIC EXAMINATION, RIBS, BILATERAL; 3 VIEWS" 9512806_1 CDM 320 RC 71110 HCPCS outpatient 498 373.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 473.1 95 999999999 388.44 473.1 percent of total billed charges "RADIOLOGIC EXAMINATION, RIBS, BILATERAL; 3 VIEWS" 9512806_1 CDM 320 RC 71110 HCPCS outpatient 498 373.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 443.22 89 999999999 388.44 473.1 percent of total billed charges "RADIOLOGIC EXAMINATION, RIBS, BILATERAL; 3 VIEWS" 9512806_1 CDM 320 RC 71110 HCPCS outpatient 498 373.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 438.24 88 999999999 388.44 473.1 percent of total billed charges "RADIOLOGIC EXAMINATION, RIBS, BILATERAL; 3 VIEWS" 9512806_1 CDM 320 RC 71110 HCPCS outpatient 498 373.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 443.22 89 999999999 388.44 473.1 percent of total billed charges "RADIOLOGIC EXAMINATION; STERNUM, MINIMUM OF 2 VIEWS" 9512812_1 CDM 320 RC 71120 HCPCS outpatient 348 261 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 313.2 90 999999999 271.44 330.6 percent of total billed charges "RADIOLOGIC EXAMINATION; STERNUM, MINIMUM OF 2 VIEWS" 9512812_1 CDM 320 RC 71120 HCPCS outpatient 348 261 AETNA MCR ADV AETNA MCR ADV 271.44 78 999999999 271.44 330.6 percent of total billed charges "RADIOLOGIC EXAMINATION; STERNUM, MINIMUM OF 2 VIEWS" 9512812_1 CDM 320 RC 71120 HCPCS outpatient 348 261 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 304.74 87.57 999999999 271.44 330.6 percent of total billed charges "RADIOLOGIC EXAMINATION; STERNUM, MINIMUM OF 2 VIEWS" 9512812_1 CDM 320 RC 71120 HCPCS outpatient 348 261 COORDINATED CARE MCAID COORDINATED CARE MCAID 296.04 85.07 999999999 271.44 330.6 percent of total billed charges "RADIOLOGIC EXAMINATION; STERNUM, MINIMUM OF 2 VIEWS" 9512812_1 CDM 320 RC 71120 HCPCS outpatient 348 261 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 296.04 85.07 999999999 271.44 330.6 percent of total billed charges "RADIOLOGIC EXAMINATION; STERNUM, MINIMUM OF 2 VIEWS" 9512812_1 CDM 320 RC 71120 HCPCS outpatient 348 261 MOLINA MCAID MOLINA MCAID 290.23 83.4 999999999 271.44 330.6 percent of total billed charges "RADIOLOGIC EXAMINATION; STERNUM, MINIMUM OF 2 VIEWS" 9512812_1 CDM 320 RC 71120 HCPCS outpatient 348 261 MOLINA MCR ADV MOLINA MCR ADV 309.72 89 999999999 271.44 330.6 percent of total billed charges "RADIOLOGIC EXAMINATION; STERNUM, MINIMUM OF 2 VIEWS" 9512812_1 CDM 320 RC 71120 HCPCS outpatient 348 261 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 309.72 89 999999999 271.44 330.6 percent of total billed charges "RADIOLOGIC EXAMINATION; STERNUM, MINIMUM OF 2 VIEWS" 9512812_1 CDM 320 RC 71120 HCPCS outpatient 348 261 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 309.72 89 999999999 271.44 330.6 percent of total billed charges "RADIOLOGIC EXAMINATION; STERNUM, MINIMUM OF 2 VIEWS" 9512812_1 CDM 320 RC 71120 HCPCS outpatient 348 261 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 313.2 90 999999999 271.44 330.6 percent of total billed charges "RADIOLOGIC EXAMINATION; STERNUM, MINIMUM OF 2 VIEWS" 9512812_1 CDM 320 RC 71120 HCPCS outpatient 348 261 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 330.6 95 999999999 271.44 330.6 percent of total billed charges "RADIOLOGIC EXAMINATION; STERNUM, MINIMUM OF 2 VIEWS" 9512812_1 CDM 320 RC 71120 HCPCS outpatient 348 261 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 330.6 95 999999999 271.44 330.6 percent of total billed charges "RADIOLOGIC EXAMINATION; STERNUM, MINIMUM OF 2 VIEWS" 9512812_1 CDM 320 RC 71120 HCPCS outpatient 348 261 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 309.72 89 999999999 271.44 330.6 percent of total billed charges "RADIOLOGIC EXAMINATION; STERNUM, MINIMUM OF 2 VIEWS" 9512812_1 CDM 320 RC 71120 HCPCS outpatient 348 261 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 306.24 88 999999999 271.44 330.6 percent of total billed charges "RADIOLOGIC EXAMINATION; STERNUM, MINIMUM OF 2 VIEWS" 9512812_1 CDM 320 RC 71120 HCPCS outpatient 348 261 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 309.72 89 999999999 271.44 330.6 percent of total billed charges "COMPUTED TOMOGRAPHY, THORAX, DIAGNOSTIC; WITH CONTRAST MATERIAL(S)" 9512821_1 CDM 352 RC 71260 HCPCS outpatient 2277 1707.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 2049.3 90 999999999 1776.06 2163.15 percent of total billed charges "COMPUTED TOMOGRAPHY, THORAX, DIAGNOSTIC; WITH CONTRAST MATERIAL(S)" 9512821_1 CDM 352 RC 71260 HCPCS outpatient 2277 1707.75 AETNA MCR ADV AETNA MCR ADV 1776.06 78 999999999 1776.06 2163.15 percent of total billed charges "COMPUTED TOMOGRAPHY, THORAX, DIAGNOSTIC; WITH CONTRAST MATERIAL(S)" 9512821_1 CDM 352 RC 71260 HCPCS outpatient 2277 1707.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1993.97 87.57 999999999 1776.06 2163.15 percent of total billed charges "COMPUTED TOMOGRAPHY, THORAX, DIAGNOSTIC; WITH CONTRAST MATERIAL(S)" 9512821_1 CDM 352 RC 71260 HCPCS outpatient 2277 1707.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 1937.04 85.07 999999999 1776.06 2163.15 percent of total billed charges "COMPUTED TOMOGRAPHY, THORAX, DIAGNOSTIC; WITH CONTRAST MATERIAL(S)" 9512821_1 CDM 352 RC 71260 HCPCS outpatient 2277 1707.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1937.04 85.07 999999999 1776.06 2163.15 percent of total billed charges "COMPUTED TOMOGRAPHY, THORAX, DIAGNOSTIC; WITH CONTRAST MATERIAL(S)" 9512821_1 CDM 352 RC 71260 HCPCS outpatient 2277 1707.75 MOLINA MCAID MOLINA MCAID 1899.02 83.4 999999999 1776.06 2163.15 percent of total billed charges "COMPUTED TOMOGRAPHY, THORAX, DIAGNOSTIC; WITH CONTRAST MATERIAL(S)" 9512821_1 CDM 352 RC 71260 HCPCS outpatient 2277 1707.75 MOLINA MCR ADV MOLINA MCR ADV 2026.53 89 999999999 1776.06 2163.15 percent of total billed charges "COMPUTED TOMOGRAPHY, THORAX, DIAGNOSTIC; WITH CONTRAST MATERIAL(S)" 9512821_1 CDM 352 RC 71260 HCPCS outpatient 2277 1707.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 2026.53 89 999999999 1776.06 2163.15 percent of total billed charges "COMPUTED TOMOGRAPHY, THORAX, DIAGNOSTIC; WITH CONTRAST MATERIAL(S)" 9512821_1 CDM 352 RC 71260 HCPCS outpatient 2277 1707.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 2026.53 89 999999999 1776.06 2163.15 percent of total billed charges "COMPUTED TOMOGRAPHY, THORAX, DIAGNOSTIC; WITH CONTRAST MATERIAL(S)" 9512821_1 CDM 352 RC 71260 HCPCS outpatient 2277 1707.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 2049.3 90 999999999 1776.06 2163.15 percent of total billed charges "COMPUTED TOMOGRAPHY, THORAX, DIAGNOSTIC; WITH CONTRAST MATERIAL(S)" 9512821_1 CDM 352 RC 71260 HCPCS outpatient 2277 1707.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 2163.15 95 999999999 1776.06 2163.15 percent of total billed charges "COMPUTED TOMOGRAPHY, THORAX, DIAGNOSTIC; WITH CONTRAST MATERIAL(S)" 9512821_1 CDM 352 RC 71260 HCPCS outpatient 2277 1707.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 2163.15 95 999999999 1776.06 2163.15 percent of total billed charges "COMPUTED TOMOGRAPHY, THORAX, DIAGNOSTIC; WITH CONTRAST MATERIAL(S)" 9512821_1 CDM 352 RC 71260 HCPCS outpatient 2277 1707.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 2026.53 89 999999999 1776.06 2163.15 percent of total billed charges "COMPUTED TOMOGRAPHY, THORAX, DIAGNOSTIC; WITH CONTRAST MATERIAL(S)" 9512821_1 CDM 352 RC 71260 HCPCS outpatient 2277 1707.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 2003.76 88 999999999 1776.06 2163.15 percent of total billed charges "COMPUTED TOMOGRAPHY, THORAX, DIAGNOSTIC; WITH CONTRAST MATERIAL(S)" 9512821_1 CDM 352 RC 71260 HCPCS outpatient 2277 1707.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 2026.53 89 999999999 1776.06 2163.15 percent of total billed charges "COMPUTED TOMOGRAPHY, THORAX, DIAGNOSTIC; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512824_1 CDM 352 RC 71270 HCPCS outpatient 2647 1985.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 2382.3 90 999999999 2064.66 2514.65 percent of total billed charges "COMPUTED TOMOGRAPHY, THORAX, DIAGNOSTIC; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512824_1 CDM 352 RC 71270 HCPCS outpatient 2647 1985.25 AETNA MCR ADV AETNA MCR ADV 2064.66 78 999999999 2064.66 2514.65 percent of total billed charges "COMPUTED TOMOGRAPHY, THORAX, DIAGNOSTIC; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512824_1 CDM 352 RC 71270 HCPCS outpatient 2647 1985.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 2317.98 87.57 999999999 2064.66 2514.65 percent of total billed charges "COMPUTED TOMOGRAPHY, THORAX, DIAGNOSTIC; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512824_1 CDM 352 RC 71270 HCPCS outpatient 2647 1985.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 2251.8 85.07 999999999 2064.66 2514.65 percent of total billed charges "COMPUTED TOMOGRAPHY, THORAX, DIAGNOSTIC; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512824_1 CDM 352 RC 71270 HCPCS outpatient 2647 1985.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 2251.8 85.07 999999999 2064.66 2514.65 percent of total billed charges "COMPUTED TOMOGRAPHY, THORAX, DIAGNOSTIC; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512824_1 CDM 352 RC 71270 HCPCS outpatient 2647 1985.25 MOLINA MCAID MOLINA MCAID 2207.6 83.4 999999999 2064.66 2514.65 percent of total billed charges "COMPUTED TOMOGRAPHY, THORAX, DIAGNOSTIC; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512824_1 CDM 352 RC 71270 HCPCS outpatient 2647 1985.25 MOLINA MCR ADV MOLINA MCR ADV 2355.83 89 999999999 2064.66 2514.65 percent of total billed charges "COMPUTED TOMOGRAPHY, THORAX, DIAGNOSTIC; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512824_1 CDM 352 RC 71270 HCPCS outpatient 2647 1985.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 2355.83 89 999999999 2064.66 2514.65 percent of total billed charges "COMPUTED TOMOGRAPHY, THORAX, DIAGNOSTIC; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512824_1 CDM 352 RC 71270 HCPCS outpatient 2647 1985.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 2355.83 89 999999999 2064.66 2514.65 percent of total billed charges "COMPUTED TOMOGRAPHY, THORAX, DIAGNOSTIC; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512824_1 CDM 352 RC 71270 HCPCS outpatient 2647 1985.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 2382.3 90 999999999 2064.66 2514.65 percent of total billed charges "COMPUTED TOMOGRAPHY, THORAX, DIAGNOSTIC; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512824_1 CDM 352 RC 71270 HCPCS outpatient 2647 1985.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 2514.65 95 999999999 2064.66 2514.65 percent of total billed charges "COMPUTED TOMOGRAPHY, THORAX, DIAGNOSTIC; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512824_1 CDM 352 RC 71270 HCPCS outpatient 2647 1985.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 2514.65 95 999999999 2064.66 2514.65 percent of total billed charges "COMPUTED TOMOGRAPHY, THORAX, DIAGNOSTIC; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512824_1 CDM 352 RC 71270 HCPCS outpatient 2647 1985.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 2355.83 89 999999999 2064.66 2514.65 percent of total billed charges "COMPUTED TOMOGRAPHY, THORAX, DIAGNOSTIC; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512824_1 CDM 352 RC 71270 HCPCS outpatient 2647 1985.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 2329.36 88 999999999 2064.66 2514.65 percent of total billed charges "COMPUTED TOMOGRAPHY, THORAX, DIAGNOSTIC; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512824_1 CDM 352 RC 71270 HCPCS outpatient 2647 1985.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 2355.83 89 999999999 2064.66 2514.65 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, CHEST (NONCORONARY), WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512827_1 CDM 352 RC 71275 HCPCS outpatient 3200 2400 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 2880 90 999999999 2496 3040 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, CHEST (NONCORONARY), WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512827_1 CDM 352 RC 71275 HCPCS outpatient 3200 2400 AETNA MCR ADV AETNA MCR ADV 2496 78 999999999 2496 3040 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, CHEST (NONCORONARY), WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512827_1 CDM 352 RC 71275 HCPCS outpatient 3200 2400 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 2802.24 87.57 999999999 2496 3040 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, CHEST (NONCORONARY), WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512827_1 CDM 352 RC 71275 HCPCS outpatient 3200 2400 COORDINATED CARE MCAID COORDINATED CARE MCAID 2722.24 85.07 999999999 2496 3040 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, CHEST (NONCORONARY), WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512827_1 CDM 352 RC 71275 HCPCS outpatient 3200 2400 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 2722.24 85.07 999999999 2496 3040 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, CHEST (NONCORONARY), WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512827_1 CDM 352 RC 71275 HCPCS outpatient 3200 2400 MOLINA MCAID MOLINA MCAID 2668.8 83.4 999999999 2496 3040 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, CHEST (NONCORONARY), WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512827_1 CDM 352 RC 71275 HCPCS outpatient 3200 2400 MOLINA MCR ADV MOLINA MCR ADV 2848 89 999999999 2496 3040 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, CHEST (NONCORONARY), WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512827_1 CDM 352 RC 71275 HCPCS outpatient 3200 2400 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 2848 89 999999999 2496 3040 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, CHEST (NONCORONARY), WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512827_1 CDM 352 RC 71275 HCPCS outpatient 3200 2400 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 2848 89 999999999 2496 3040 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, CHEST (NONCORONARY), WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512827_1 CDM 352 RC 71275 HCPCS outpatient 3200 2400 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 2880 90 999999999 2496 3040 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, CHEST (NONCORONARY), WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512827_1 CDM 352 RC 71275 HCPCS outpatient 3200 2400 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 3040 95 999999999 2496 3040 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, CHEST (NONCORONARY), WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512827_1 CDM 352 RC 71275 HCPCS outpatient 3200 2400 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 3040 95 999999999 2496 3040 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, CHEST (NONCORONARY), WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512827_1 CDM 352 RC 71275 HCPCS outpatient 3200 2400 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 2848 89 999999999 2496 3040 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, CHEST (NONCORONARY), WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512827_1 CDM 352 RC 71275 HCPCS outpatient 3200 2400 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 2816 88 999999999 2496 3040 percent of total billed charges "COMPUTED TOMOGRAPHIC ANGIOGRAPHY, CHEST (NONCORONARY), WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING" 9512827_1 CDM 352 RC 71275 HCPCS outpatient 3200 2400 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 2848 89 999999999 2496 3040 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR EVALUATION OF HILAR AND MEDIASTINAL LYMPHADENOPATHY); WITHOUT CONTRAST MATERIAL(S)" 9512830_1 CDM 610 RC 71550 HCPCS outpatient 2030 1522.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1827 90 999999999 1583.4 1928.5 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR EVALUATION OF HILAR AND MEDIASTINAL LYMPHADENOPATHY); WITHOUT CONTRAST MATERIAL(S)" 9512830_1 CDM 610 RC 71550 HCPCS outpatient 2030 1522.5 AETNA MCR ADV AETNA MCR ADV 1583.4 78 999999999 1583.4 1928.5 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR EVALUATION OF HILAR AND MEDIASTINAL LYMPHADENOPATHY); WITHOUT CONTRAST MATERIAL(S)" 9512830_1 CDM 610 RC 71550 HCPCS outpatient 2030 1522.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1777.67 87.57 999999999 1583.4 1928.5 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR EVALUATION OF HILAR AND MEDIASTINAL LYMPHADENOPATHY); WITHOUT CONTRAST MATERIAL(S)" 9512830_1 CDM 610 RC 71550 HCPCS outpatient 2030 1522.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 1726.92 85.07 999999999 1583.4 1928.5 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR EVALUATION OF HILAR AND MEDIASTINAL LYMPHADENOPATHY); WITHOUT CONTRAST MATERIAL(S)" 9512830_1 CDM 610 RC 71550 HCPCS outpatient 2030 1522.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1726.92 85.07 999999999 1583.4 1928.5 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR EVALUATION OF HILAR AND MEDIASTINAL LYMPHADENOPATHY); WITHOUT CONTRAST MATERIAL(S)" 9512830_1 CDM 610 RC 71550 HCPCS outpatient 2030 1522.5 MOLINA MCAID MOLINA MCAID 1693.02 83.4 999999999 1583.4 1928.5 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR EVALUATION OF HILAR AND MEDIASTINAL LYMPHADENOPATHY); WITHOUT CONTRAST MATERIAL(S)" 9512830_1 CDM 610 RC 71550 HCPCS outpatient 2030 1522.5 MOLINA MCR ADV MOLINA MCR ADV 1806.7 89 999999999 1583.4 1928.5 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR EVALUATION OF HILAR AND MEDIASTINAL LYMPHADENOPATHY); WITHOUT CONTRAST MATERIAL(S)" 9512830_1 CDM 610 RC 71550 HCPCS outpatient 2030 1522.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1806.7 89 999999999 1583.4 1928.5 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR EVALUATION OF HILAR AND MEDIASTINAL LYMPHADENOPATHY); WITHOUT CONTRAST MATERIAL(S)" 9512830_1 CDM 610 RC 71550 HCPCS outpatient 2030 1522.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1806.7 89 999999999 1583.4 1928.5 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR EVALUATION OF HILAR AND MEDIASTINAL LYMPHADENOPATHY); WITHOUT CONTRAST MATERIAL(S)" 9512830_1 CDM 610 RC 71550 HCPCS outpatient 2030 1522.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1827 90 999999999 1583.4 1928.5 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR EVALUATION OF HILAR AND MEDIASTINAL LYMPHADENOPATHY); WITHOUT CONTRAST MATERIAL(S)" 9512830_1 CDM 610 RC 71550 HCPCS outpatient 2030 1522.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1928.5 95 999999999 1583.4 1928.5 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR EVALUATION OF HILAR AND MEDIASTINAL LYMPHADENOPATHY); WITHOUT CONTRAST MATERIAL(S)" 9512830_1 CDM 610 RC 71550 HCPCS outpatient 2030 1522.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1928.5 95 999999999 1583.4 1928.5 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR EVALUATION OF HILAR AND MEDIASTINAL LYMPHADENOPATHY); WITHOUT CONTRAST MATERIAL(S)" 9512830_1 CDM 610 RC 71550 HCPCS outpatient 2030 1522.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1806.7 89 999999999 1583.4 1928.5 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR EVALUATION OF HILAR AND MEDIASTINAL LYMPHADENOPATHY); WITHOUT CONTRAST MATERIAL(S)" 9512830_1 CDM 610 RC 71550 HCPCS outpatient 2030 1522.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1786.4 88 999999999 1583.4 1928.5 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR EVALUATION OF HILAR AND MEDIASTINAL LYMPHADENOPATHY); WITHOUT CONTRAST MATERIAL(S)" 9512830_1 CDM 610 RC 71550 HCPCS outpatient 2030 1522.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1806.7 89 999999999 1583.4 1928.5 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, SINGLE VIEW, SPECIFY LEVEL" 9512836_1 CDM 320 RC 72020 HCPCS outpatient 321 240.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 288.9 90 999999999 250.38 304.95 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, SINGLE VIEW, SPECIFY LEVEL" 9512836_1 CDM 320 RC 72020 HCPCS outpatient 321 240.75 AETNA MCR ADV AETNA MCR ADV 250.38 78 999999999 250.38 304.95 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, SINGLE VIEW, SPECIFY LEVEL" 9512836_1 CDM 320 RC 72020 HCPCS outpatient 321 240.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 281.1 87.57 999999999 250.38 304.95 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, SINGLE VIEW, SPECIFY LEVEL" 9512836_1 CDM 320 RC 72020 HCPCS outpatient 321 240.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 273.07 85.07 999999999 250.38 304.95 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, SINGLE VIEW, SPECIFY LEVEL" 9512836_1 CDM 320 RC 72020 HCPCS outpatient 321 240.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 273.07 85.07 999999999 250.38 304.95 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, SINGLE VIEW, SPECIFY LEVEL" 9512836_1 CDM 320 RC 72020 HCPCS outpatient 321 240.75 MOLINA MCAID MOLINA MCAID 267.71 83.4 999999999 250.38 304.95 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, SINGLE VIEW, SPECIFY LEVEL" 9512836_1 CDM 320 RC 72020 HCPCS outpatient 321 240.75 MOLINA MCR ADV MOLINA MCR ADV 285.69 89 999999999 250.38 304.95 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, SINGLE VIEW, SPECIFY LEVEL" 9512836_1 CDM 320 RC 72020 HCPCS outpatient 321 240.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 285.69 89 999999999 250.38 304.95 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, SINGLE VIEW, SPECIFY LEVEL" 9512836_1 CDM 320 RC 72020 HCPCS outpatient 321 240.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 285.69 89 999999999 250.38 304.95 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, SINGLE VIEW, SPECIFY LEVEL" 9512836_1 CDM 320 RC 72020 HCPCS outpatient 321 240.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 288.9 90 999999999 250.38 304.95 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, SINGLE VIEW, SPECIFY LEVEL" 9512836_1 CDM 320 RC 72020 HCPCS outpatient 321 240.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 304.95 95 999999999 250.38 304.95 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, SINGLE VIEW, SPECIFY LEVEL" 9512836_1 CDM 320 RC 72020 HCPCS outpatient 321 240.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 304.95 95 999999999 250.38 304.95 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, SINGLE VIEW, SPECIFY LEVEL" 9512836_1 CDM 320 RC 72020 HCPCS outpatient 321 240.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 285.69 89 999999999 250.38 304.95 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, SINGLE VIEW, SPECIFY LEVEL" 9512836_1 CDM 320 RC 72020 HCPCS outpatient 321 240.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 282.48 88 999999999 250.38 304.95 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, SINGLE VIEW, SPECIFY LEVEL" 9512836_1 CDM 320 RC 72020 HCPCS outpatient 321 240.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 285.69 89 999999999 250.38 304.95 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 2 OR 3 VIEWS" 9512839_1 CDM 320 RC 72040 HCPCS outpatient 367 275.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 330.3 90 999999999 286.26 348.65 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 2 OR 3 VIEWS" 9512839_1 CDM 320 RC 72040 HCPCS outpatient 367 275.25 AETNA MCR ADV AETNA MCR ADV 286.26 78 999999999 286.26 348.65 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 2 OR 3 VIEWS" 9512839_1 CDM 320 RC 72040 HCPCS outpatient 367 275.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 321.38 87.57 999999999 286.26 348.65 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 2 OR 3 VIEWS" 9512839_1 CDM 320 RC 72040 HCPCS outpatient 367 275.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 312.21 85.07 999999999 286.26 348.65 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 2 OR 3 VIEWS" 9512839_1 CDM 320 RC 72040 HCPCS outpatient 367 275.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 312.21 85.07 999999999 286.26 348.65 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 2 OR 3 VIEWS" 9512839_1 CDM 320 RC 72040 HCPCS outpatient 367 275.25 MOLINA MCAID MOLINA MCAID 306.08 83.4 999999999 286.26 348.65 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 2 OR 3 VIEWS" 9512839_1 CDM 320 RC 72040 HCPCS outpatient 367 275.25 MOLINA MCR ADV MOLINA MCR ADV 326.63 89 999999999 286.26 348.65 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 2 OR 3 VIEWS" 9512839_1 CDM 320 RC 72040 HCPCS outpatient 367 275.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 326.63 89 999999999 286.26 348.65 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 2 OR 3 VIEWS" 9512839_1 CDM 320 RC 72040 HCPCS outpatient 367 275.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 326.63 89 999999999 286.26 348.65 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 2 OR 3 VIEWS" 9512839_1 CDM 320 RC 72040 HCPCS outpatient 367 275.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 330.3 90 999999999 286.26 348.65 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 2 OR 3 VIEWS" 9512839_1 CDM 320 RC 72040 HCPCS outpatient 367 275.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 348.65 95 999999999 286.26 348.65 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 2 OR 3 VIEWS" 9512839_1 CDM 320 RC 72040 HCPCS outpatient 367 275.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 348.65 95 999999999 286.26 348.65 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 2 OR 3 VIEWS" 9512839_1 CDM 320 RC 72040 HCPCS outpatient 367 275.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 326.63 89 999999999 286.26 348.65 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 2 OR 3 VIEWS" 9512839_1 CDM 320 RC 72040 HCPCS outpatient 367 275.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 322.96 88 999999999 286.26 348.65 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 2 OR 3 VIEWS" 9512839_1 CDM 320 RC 72040 HCPCS outpatient 367 275.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 326.63 89 999999999 286.26 348.65 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACIC, 2 VIEWS" 9512851_1 CDM 320 RC 72070 HCPCS outpatient 380 285 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 342 90 999999999 296.4 361 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACIC, 2 VIEWS" 9512851_1 CDM 320 RC 72070 HCPCS outpatient 380 285 AETNA MCR ADV AETNA MCR ADV 296.4 78 999999999 296.4 361 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACIC, 2 VIEWS" 9512851_1 CDM 320 RC 72070 HCPCS outpatient 380 285 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 332.77 87.57 999999999 296.4 361 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACIC, 2 VIEWS" 9512851_1 CDM 320 RC 72070 HCPCS outpatient 380 285 COORDINATED CARE MCAID COORDINATED CARE MCAID 323.27 85.07 999999999 296.4 361 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACIC, 2 VIEWS" 9512851_1 CDM 320 RC 72070 HCPCS outpatient 380 285 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 323.27 85.07 999999999 296.4 361 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACIC, 2 VIEWS" 9512851_1 CDM 320 RC 72070 HCPCS outpatient 380 285 MOLINA MCAID MOLINA MCAID 316.92 83.4 999999999 296.4 361 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACIC, 2 VIEWS" 9512851_1 CDM 320 RC 72070 HCPCS outpatient 380 285 MOLINA MCR ADV MOLINA MCR ADV 338.2 89 999999999 296.4 361 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACIC, 2 VIEWS" 9512851_1 CDM 320 RC 72070 HCPCS outpatient 380 285 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 338.2 89 999999999 296.4 361 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACIC, 2 VIEWS" 9512851_1 CDM 320 RC 72070 HCPCS outpatient 380 285 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 338.2 89 999999999 296.4 361 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACIC, 2 VIEWS" 9512851_1 CDM 320 RC 72070 HCPCS outpatient 380 285 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 342 90 999999999 296.4 361 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACIC, 2 VIEWS" 9512851_1 CDM 320 RC 72070 HCPCS outpatient 380 285 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 361 95 999999999 296.4 361 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACIC, 2 VIEWS" 9512851_1 CDM 320 RC 72070 HCPCS outpatient 380 285 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 361 95 999999999 296.4 361 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACIC, 2 VIEWS" 9512851_1 CDM 320 RC 72070 HCPCS outpatient 380 285 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 338.2 89 999999999 296.4 361 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACIC, 2 VIEWS" 9512851_1 CDM 320 RC 72070 HCPCS outpatient 380 285 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 334.4 88 999999999 296.4 361 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACIC, 2 VIEWS" 9512851_1 CDM 320 RC 72070 HCPCS outpatient 380 285 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 338.2 89 999999999 296.4 361 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACIC, 3 VIEWS" 9512854_1 CDM 320 RC 72072 HCPCS outpatient 420 315 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 378 90 999999999 327.6 399 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACIC, 3 VIEWS" 9512854_1 CDM 320 RC 72072 HCPCS outpatient 420 315 AETNA MCR ADV AETNA MCR ADV 327.6 78 999999999 327.6 399 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACIC, 3 VIEWS" 9512854_1 CDM 320 RC 72072 HCPCS outpatient 420 315 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 367.79 87.57 999999999 327.6 399 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACIC, 3 VIEWS" 9512854_1 CDM 320 RC 72072 HCPCS outpatient 420 315 COORDINATED CARE MCAID COORDINATED CARE MCAID 357.29 85.07 999999999 327.6 399 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACIC, 3 VIEWS" 9512854_1 CDM 320 RC 72072 HCPCS outpatient 420 315 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 357.29 85.07 999999999 327.6 399 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACIC, 3 VIEWS" 9512854_1 CDM 320 RC 72072 HCPCS outpatient 420 315 MOLINA MCAID MOLINA MCAID 350.28 83.4 999999999 327.6 399 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACIC, 3 VIEWS" 9512854_1 CDM 320 RC 72072 HCPCS outpatient 420 315 MOLINA MCR ADV MOLINA MCR ADV 373.8 89 999999999 327.6 399 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACIC, 3 VIEWS" 9512854_1 CDM 320 RC 72072 HCPCS outpatient 420 315 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 373.8 89 999999999 327.6 399 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACIC, 3 VIEWS" 9512854_1 CDM 320 RC 72072 HCPCS outpatient 420 315 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 373.8 89 999999999 327.6 399 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACIC, 3 VIEWS" 9512854_1 CDM 320 RC 72072 HCPCS outpatient 420 315 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 378 90 999999999 327.6 399 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACIC, 3 VIEWS" 9512854_1 CDM 320 RC 72072 HCPCS outpatient 420 315 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 399 95 999999999 327.6 399 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACIC, 3 VIEWS" 9512854_1 CDM 320 RC 72072 HCPCS outpatient 420 315 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 399 95 999999999 327.6 399 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACIC, 3 VIEWS" 9512854_1 CDM 320 RC 72072 HCPCS outpatient 420 315 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 373.8 89 999999999 327.6 399 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACIC, 3 VIEWS" 9512854_1 CDM 320 RC 72072 HCPCS outpatient 420 315 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 369.6 88 999999999 327.6 399 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACIC, 3 VIEWS" 9512854_1 CDM 320 RC 72072 HCPCS outpatient 420 315 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 373.8 89 999999999 327.6 399 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACOLUMBAR JUNCTION, MINIMUM OF 2 VIEWS" 9512860_1 CDM 320 RC 72080 HCPCS outpatient 450 337.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 405 90 999999999 351 427.5 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACOLUMBAR JUNCTION, MINIMUM OF 2 VIEWS" 9512860_1 CDM 320 RC 72080 HCPCS outpatient 450 337.5 AETNA MCR ADV AETNA MCR ADV 351 78 999999999 351 427.5 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACOLUMBAR JUNCTION, MINIMUM OF 2 VIEWS" 9512860_1 CDM 320 RC 72080 HCPCS outpatient 450 337.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 394.07 87.57 999999999 351 427.5 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACOLUMBAR JUNCTION, MINIMUM OF 2 VIEWS" 9512860_1 CDM 320 RC 72080 HCPCS outpatient 450 337.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 382.82 85.07 999999999 351 427.5 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACOLUMBAR JUNCTION, MINIMUM OF 2 VIEWS" 9512860_1 CDM 320 RC 72080 HCPCS outpatient 450 337.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 382.82 85.07 999999999 351 427.5 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACOLUMBAR JUNCTION, MINIMUM OF 2 VIEWS" 9512860_1 CDM 320 RC 72080 HCPCS outpatient 450 337.5 MOLINA MCAID MOLINA MCAID 375.3 83.4 999999999 351 427.5 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACOLUMBAR JUNCTION, MINIMUM OF 2 VIEWS" 9512860_1 CDM 320 RC 72080 HCPCS outpatient 450 337.5 MOLINA MCR ADV MOLINA MCR ADV 400.5 89 999999999 351 427.5 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACOLUMBAR JUNCTION, MINIMUM OF 2 VIEWS" 9512860_1 CDM 320 RC 72080 HCPCS outpatient 450 337.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 400.5 89 999999999 351 427.5 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACOLUMBAR JUNCTION, MINIMUM OF 2 VIEWS" 9512860_1 CDM 320 RC 72080 HCPCS outpatient 450 337.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 400.5 89 999999999 351 427.5 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACOLUMBAR JUNCTION, MINIMUM OF 2 VIEWS" 9512860_1 CDM 320 RC 72080 HCPCS outpatient 450 337.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 405 90 999999999 351 427.5 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACOLUMBAR JUNCTION, MINIMUM OF 2 VIEWS" 9512860_1 CDM 320 RC 72080 HCPCS outpatient 450 337.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 427.5 95 999999999 351 427.5 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACOLUMBAR JUNCTION, MINIMUM OF 2 VIEWS" 9512860_1 CDM 320 RC 72080 HCPCS outpatient 450 337.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 427.5 95 999999999 351 427.5 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACOLUMBAR JUNCTION, MINIMUM OF 2 VIEWS" 9512860_1 CDM 320 RC 72080 HCPCS outpatient 450 337.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 400.5 89 999999999 351 427.5 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACOLUMBAR JUNCTION, MINIMUM OF 2 VIEWS" 9512860_1 CDM 320 RC 72080 HCPCS outpatient 450 337.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 396 88 999999999 351 427.5 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE; THORACOLUMBAR JUNCTION, MINIMUM OF 2 VIEWS" 9512860_1 CDM 320 RC 72080 HCPCS outpatient 450 337.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 400.5 89 999999999 351 427.5 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; 2 OR 3 VIEWS" 9512866_1 CDM 320 RC 72100 HCPCS outpatient 398 298.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 358.2 90 999999999 310.44 378.1 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; 2 OR 3 VIEWS" 9512866_1 CDM 320 RC 72100 HCPCS outpatient 398 298.5 AETNA MCR ADV AETNA MCR ADV 310.44 78 999999999 310.44 378.1 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; 2 OR 3 VIEWS" 9512866_1 CDM 320 RC 72100 HCPCS outpatient 398 298.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 348.53 87.57 999999999 310.44 378.1 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; 2 OR 3 VIEWS" 9512866_1 CDM 320 RC 72100 HCPCS outpatient 398 298.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 338.58 85.07 999999999 310.44 378.1 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; 2 OR 3 VIEWS" 9512866_1 CDM 320 RC 72100 HCPCS outpatient 398 298.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 338.58 85.07 999999999 310.44 378.1 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; 2 OR 3 VIEWS" 9512866_1 CDM 320 RC 72100 HCPCS outpatient 398 298.5 MOLINA MCAID MOLINA MCAID 331.93 83.4 999999999 310.44 378.1 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; 2 OR 3 VIEWS" 9512866_1 CDM 320 RC 72100 HCPCS outpatient 398 298.5 MOLINA MCR ADV MOLINA MCR ADV 354.22 89 999999999 310.44 378.1 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; 2 OR 3 VIEWS" 9512866_1 CDM 320 RC 72100 HCPCS outpatient 398 298.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 354.22 89 999999999 310.44 378.1 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; 2 OR 3 VIEWS" 9512866_1 CDM 320 RC 72100 HCPCS outpatient 398 298.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 354.22 89 999999999 310.44 378.1 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; 2 OR 3 VIEWS" 9512866_1 CDM 320 RC 72100 HCPCS outpatient 398 298.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 358.2 90 999999999 310.44 378.1 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; 2 OR 3 VIEWS" 9512866_1 CDM 320 RC 72100 HCPCS outpatient 398 298.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 378.1 95 999999999 310.44 378.1 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; 2 OR 3 VIEWS" 9512866_1 CDM 320 RC 72100 HCPCS outpatient 398 298.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 378.1 95 999999999 310.44 378.1 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; 2 OR 3 VIEWS" 9512866_1 CDM 320 RC 72100 HCPCS outpatient 398 298.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 354.22 89 999999999 310.44 378.1 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; 2 OR 3 VIEWS" 9512866_1 CDM 320 RC 72100 HCPCS outpatient 398 298.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 350.24 88 999999999 310.44 378.1 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; 2 OR 3 VIEWS" 9512866_1 CDM 320 RC 72100 HCPCS outpatient 398 298.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 354.22 89 999999999 310.44 378.1 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; MINIMUM OF 4 VIEWS" 9512869_1 CDM 320 RC 72110 HCPCS outpatient 476 357 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 428.4 90 999999999 371.28 452.2 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; MINIMUM OF 4 VIEWS" 9512869_1 CDM 320 RC 72110 HCPCS outpatient 476 357 AETNA MCR ADV AETNA MCR ADV 371.28 78 999999999 371.28 452.2 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; MINIMUM OF 4 VIEWS" 9512869_1 CDM 320 RC 72110 HCPCS outpatient 476 357 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 416.83 87.57 999999999 371.28 452.2 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; MINIMUM OF 4 VIEWS" 9512869_1 CDM 320 RC 72110 HCPCS outpatient 476 357 COORDINATED CARE MCAID COORDINATED CARE MCAID 404.93 85.07 999999999 371.28 452.2 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; MINIMUM OF 4 VIEWS" 9512869_1 CDM 320 RC 72110 HCPCS outpatient 476 357 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 404.93 85.07 999999999 371.28 452.2 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; MINIMUM OF 4 VIEWS" 9512869_1 CDM 320 RC 72110 HCPCS outpatient 476 357 MOLINA MCAID MOLINA MCAID 396.98 83.4 999999999 371.28 452.2 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; MINIMUM OF 4 VIEWS" 9512869_1 CDM 320 RC 72110 HCPCS outpatient 476 357 MOLINA MCR ADV MOLINA MCR ADV 423.64 89 999999999 371.28 452.2 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; MINIMUM OF 4 VIEWS" 9512869_1 CDM 320 RC 72110 HCPCS outpatient 476 357 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 423.64 89 999999999 371.28 452.2 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; MINIMUM OF 4 VIEWS" 9512869_1 CDM 320 RC 72110 HCPCS outpatient 476 357 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 423.64 89 999999999 371.28 452.2 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; MINIMUM OF 4 VIEWS" 9512869_1 CDM 320 RC 72110 HCPCS outpatient 476 357 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 428.4 90 999999999 371.28 452.2 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; MINIMUM OF 4 VIEWS" 9512869_1 CDM 320 RC 72110 HCPCS outpatient 476 357 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 452.2 95 999999999 371.28 452.2 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; MINIMUM OF 4 VIEWS" 9512869_1 CDM 320 RC 72110 HCPCS outpatient 476 357 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 452.2 95 999999999 371.28 452.2 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; MINIMUM OF 4 VIEWS" 9512869_1 CDM 320 RC 72110 HCPCS outpatient 476 357 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 423.64 89 999999999 371.28 452.2 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; MINIMUM OF 4 VIEWS" 9512869_1 CDM 320 RC 72110 HCPCS outpatient 476 357 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 418.88 88 999999999 371.28 452.2 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; MINIMUM OF 4 VIEWS" 9512869_1 CDM 320 RC 72110 HCPCS outpatient 476 357 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 423.64 89 999999999 371.28 452.2 percent of total billed charges "COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITHOUT CONTRAST MATERIAL" 9512878_1 CDM 352 RC 72125 HCPCS outpatient 1631 1223.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1467.9 90 999999999 1272.18 1549.45 percent of total billed charges "COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITHOUT CONTRAST MATERIAL" 9512878_1 CDM 352 RC 72125 HCPCS outpatient 1631 1223.25 AETNA MCR ADV AETNA MCR ADV 1272.18 78 999999999 1272.18 1549.45 percent of total billed charges "COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITHOUT CONTRAST MATERIAL" 9512878_1 CDM 352 RC 72125 HCPCS outpatient 1631 1223.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1428.27 87.57 999999999 1272.18 1549.45 percent of total billed charges "COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITHOUT CONTRAST MATERIAL" 9512878_1 CDM 352 RC 72125 HCPCS outpatient 1631 1223.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 1387.49 85.07 999999999 1272.18 1549.45 percent of total billed charges "COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITHOUT CONTRAST MATERIAL" 9512878_1 CDM 352 RC 72125 HCPCS outpatient 1631 1223.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1387.49 85.07 999999999 1272.18 1549.45 percent of total billed charges "COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITHOUT CONTRAST MATERIAL" 9512878_1 CDM 352 RC 72125 HCPCS outpatient 1631 1223.25 MOLINA MCAID MOLINA MCAID 1360.25 83.4 999999999 1272.18 1549.45 percent of total billed charges "COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITHOUT CONTRAST MATERIAL" 9512878_1 CDM 352 RC 72125 HCPCS outpatient 1631 1223.25 MOLINA MCR ADV MOLINA MCR ADV 1451.59 89 999999999 1272.18 1549.45 percent of total billed charges "COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITHOUT CONTRAST MATERIAL" 9512878_1 CDM 352 RC 72125 HCPCS outpatient 1631 1223.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1451.59 89 999999999 1272.18 1549.45 percent of total billed charges "COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITHOUT CONTRAST MATERIAL" 9512878_1 CDM 352 RC 72125 HCPCS outpatient 1631 1223.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1451.59 89 999999999 1272.18 1549.45 percent of total billed charges "COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITHOUT CONTRAST MATERIAL" 9512878_1 CDM 352 RC 72125 HCPCS outpatient 1631 1223.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1467.9 90 999999999 1272.18 1549.45 percent of total billed charges "COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITHOUT CONTRAST MATERIAL" 9512878_1 CDM 352 RC 72125 HCPCS outpatient 1631 1223.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1549.45 95 999999999 1272.18 1549.45 percent of total billed charges "COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITHOUT CONTRAST MATERIAL" 9512878_1 CDM 352 RC 72125 HCPCS outpatient 1631 1223.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1549.45 95 999999999 1272.18 1549.45 percent of total billed charges "COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITHOUT CONTRAST MATERIAL" 9512878_1 CDM 352 RC 72125 HCPCS outpatient 1631 1223.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1451.59 89 999999999 1272.18 1549.45 percent of total billed charges "COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITHOUT CONTRAST MATERIAL" 9512878_1 CDM 352 RC 72125 HCPCS outpatient 1631 1223.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1435.28 88 999999999 1272.18 1549.45 percent of total billed charges "COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITHOUT CONTRAST MATERIAL" 9512878_1 CDM 352 RC 72125 HCPCS outpatient 1631 1223.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1451.59 89 999999999 1272.18 1549.45 percent of total billed charges "COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITH CONTRAST MATERIAL" 9512881_1 CDM 352 RC 72126 HCPCS outpatient 2143 1607.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1928.7 90 999999999 1671.54 2035.85 percent of total billed charges "COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITH CONTRAST MATERIAL" 9512881_1 CDM 352 RC 72126 HCPCS outpatient 2143 1607.25 AETNA MCR ADV AETNA MCR ADV 1671.54 78 999999999 1671.54 2035.85 percent of total billed charges "COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITH CONTRAST MATERIAL" 9512881_1 CDM 352 RC 72126 HCPCS outpatient 2143 1607.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1876.63 87.57 999999999 1671.54 2035.85 percent of total billed charges "COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITH CONTRAST MATERIAL" 9512881_1 CDM 352 RC 72126 HCPCS outpatient 2143 1607.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 1823.05 85.07 999999999 1671.54 2035.85 percent of total billed charges "COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITH CONTRAST MATERIAL" 9512881_1 CDM 352 RC 72126 HCPCS outpatient 2143 1607.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1823.05 85.07 999999999 1671.54 2035.85 percent of total billed charges "COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITH CONTRAST MATERIAL" 9512881_1 CDM 352 RC 72126 HCPCS outpatient 2143 1607.25 MOLINA MCAID MOLINA MCAID 1787.26 83.4 999999999 1671.54 2035.85 percent of total billed charges "COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITH CONTRAST MATERIAL" 9512881_1 CDM 352 RC 72126 HCPCS outpatient 2143 1607.25 MOLINA MCR ADV MOLINA MCR ADV 1907.27 89 999999999 1671.54 2035.85 percent of total billed charges "COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITH CONTRAST MATERIAL" 9512881_1 CDM 352 RC 72126 HCPCS outpatient 2143 1607.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1907.27 89 999999999 1671.54 2035.85 percent of total billed charges "COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITH CONTRAST MATERIAL" 9512881_1 CDM 352 RC 72126 HCPCS outpatient 2143 1607.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1907.27 89 999999999 1671.54 2035.85 percent of total billed charges "COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITH CONTRAST MATERIAL" 9512881_1 CDM 352 RC 72126 HCPCS outpatient 2143 1607.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1928.7 90 999999999 1671.54 2035.85 percent of total billed charges "COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITH CONTRAST MATERIAL" 9512881_1 CDM 352 RC 72126 HCPCS outpatient 2143 1607.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 2035.85 95 999999999 1671.54 2035.85 percent of total billed charges "COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITH CONTRAST MATERIAL" 9512881_1 CDM 352 RC 72126 HCPCS outpatient 2143 1607.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 2035.85 95 999999999 1671.54 2035.85 percent of total billed charges "COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITH CONTRAST MATERIAL" 9512881_1 CDM 352 RC 72126 HCPCS outpatient 2143 1607.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1907.27 89 999999999 1671.54 2035.85 percent of total billed charges "COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITH CONTRAST MATERIAL" 9512881_1 CDM 352 RC 72126 HCPCS outpatient 2143 1607.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1885.84 88 999999999 1671.54 2035.85 percent of total billed charges "COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITH CONTRAST MATERIAL" 9512881_1 CDM 352 RC 72126 HCPCS outpatient 2143 1607.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1907.27 89 999999999 1671.54 2035.85 percent of total billed charges "COMPUTED TOMOGRAPHY, THORACIC SPINE; WITHOUT CONTRAST MATERIAL" 9512887_1 CDM 352 RC 72128 HCPCS outpatient 1582 1186.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1423.8 90 999999999 1233.96 1502.9 percent of total billed charges "COMPUTED TOMOGRAPHY, THORACIC SPINE; WITHOUT CONTRAST MATERIAL" 9512887_1 CDM 352 RC 72128 HCPCS outpatient 1582 1186.5 AETNA MCR ADV AETNA MCR ADV 1233.96 78 999999999 1233.96 1502.9 percent of total billed charges "COMPUTED TOMOGRAPHY, THORACIC SPINE; WITHOUT CONTRAST MATERIAL" 9512887_1 CDM 352 RC 72128 HCPCS outpatient 1582 1186.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1385.36 87.57 999999999 1233.96 1502.9 percent of total billed charges "COMPUTED TOMOGRAPHY, THORACIC SPINE; WITHOUT CONTRAST MATERIAL" 9512887_1 CDM 352 RC 72128 HCPCS outpatient 1582 1186.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 1345.81 85.07 999999999 1233.96 1502.9 percent of total billed charges "COMPUTED TOMOGRAPHY, THORACIC SPINE; WITHOUT CONTRAST MATERIAL" 9512887_1 CDM 352 RC 72128 HCPCS outpatient 1582 1186.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1345.81 85.07 999999999 1233.96 1502.9 percent of total billed charges "COMPUTED TOMOGRAPHY, THORACIC SPINE; WITHOUT CONTRAST MATERIAL" 9512887_1 CDM 352 RC 72128 HCPCS outpatient 1582 1186.5 MOLINA MCAID MOLINA MCAID 1319.39 83.4 999999999 1233.96 1502.9 percent of total billed charges "COMPUTED TOMOGRAPHY, THORACIC SPINE; WITHOUT CONTRAST MATERIAL" 9512887_1 CDM 352 RC 72128 HCPCS outpatient 1582 1186.5 MOLINA MCR ADV MOLINA MCR ADV 1407.98 89 999999999 1233.96 1502.9 percent of total billed charges "COMPUTED TOMOGRAPHY, THORACIC SPINE; WITHOUT CONTRAST MATERIAL" 9512887_1 CDM 352 RC 72128 HCPCS outpatient 1582 1186.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1407.98 89 999999999 1233.96 1502.9 percent of total billed charges "COMPUTED TOMOGRAPHY, THORACIC SPINE; WITHOUT CONTRAST MATERIAL" 9512887_1 CDM 352 RC 72128 HCPCS outpatient 1582 1186.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1407.98 89 999999999 1233.96 1502.9 percent of total billed charges "COMPUTED TOMOGRAPHY, THORACIC SPINE; WITHOUT CONTRAST MATERIAL" 9512887_1 CDM 352 RC 72128 HCPCS outpatient 1582 1186.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1423.8 90 999999999 1233.96 1502.9 percent of total billed charges "COMPUTED TOMOGRAPHY, THORACIC SPINE; WITHOUT CONTRAST MATERIAL" 9512887_1 CDM 352 RC 72128 HCPCS outpatient 1582 1186.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1502.9 95 999999999 1233.96 1502.9 percent of total billed charges "COMPUTED TOMOGRAPHY, THORACIC SPINE; WITHOUT CONTRAST MATERIAL" 9512887_1 CDM 352 RC 72128 HCPCS outpatient 1582 1186.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1502.9 95 999999999 1233.96 1502.9 percent of total billed charges "COMPUTED TOMOGRAPHY, THORACIC SPINE; WITHOUT CONTRAST MATERIAL" 9512887_1 CDM 352 RC 72128 HCPCS outpatient 1582 1186.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1407.98 89 999999999 1233.96 1502.9 percent of total billed charges "COMPUTED TOMOGRAPHY, THORACIC SPINE; WITHOUT CONTRAST MATERIAL" 9512887_1 CDM 352 RC 72128 HCPCS outpatient 1582 1186.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1392.16 88 999999999 1233.96 1502.9 percent of total billed charges "COMPUTED TOMOGRAPHY, THORACIC SPINE; WITHOUT CONTRAST MATERIAL" 9512887_1 CDM 352 RC 72128 HCPCS outpatient 1582 1186.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1407.98 89 999999999 1233.96 1502.9 percent of total billed charges "COMPUTED TOMOGRAPHY, LUMBAR SPINE; WITHOUT CONTRAST MATERIAL" 9512896_1 CDM 352 RC 72131 HCPCS outpatient 1810 1357.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1629 90 999999999 1411.8 1719.5 percent of total billed charges "COMPUTED TOMOGRAPHY, LUMBAR SPINE; WITHOUT CONTRAST MATERIAL" 9512896_1 CDM 352 RC 72131 HCPCS outpatient 1810 1357.5 AETNA MCR ADV AETNA MCR ADV 1411.8 78 999999999 1411.8 1719.5 percent of total billed charges "COMPUTED TOMOGRAPHY, LUMBAR SPINE; WITHOUT CONTRAST MATERIAL" 9512896_1 CDM 352 RC 72131 HCPCS outpatient 1810 1357.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1585.02 87.57 999999999 1411.8 1719.5 percent of total billed charges "COMPUTED TOMOGRAPHY, LUMBAR SPINE; WITHOUT CONTRAST MATERIAL" 9512896_1 CDM 352 RC 72131 HCPCS outpatient 1810 1357.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 1539.77 85.07 999999999 1411.8 1719.5 percent of total billed charges "COMPUTED TOMOGRAPHY, LUMBAR SPINE; WITHOUT CONTRAST MATERIAL" 9512896_1 CDM 352 RC 72131 HCPCS outpatient 1810 1357.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1539.77 85.07 999999999 1411.8 1719.5 percent of total billed charges "COMPUTED TOMOGRAPHY, LUMBAR SPINE; WITHOUT CONTRAST MATERIAL" 9512896_1 CDM 352 RC 72131 HCPCS outpatient 1810 1357.5 MOLINA MCAID MOLINA MCAID 1509.54 83.4 999999999 1411.8 1719.5 percent of total billed charges "COMPUTED TOMOGRAPHY, LUMBAR SPINE; WITHOUT CONTRAST MATERIAL" 9512896_1 CDM 352 RC 72131 HCPCS outpatient 1810 1357.5 MOLINA MCR ADV MOLINA MCR ADV 1610.9 89 999999999 1411.8 1719.5 percent of total billed charges "COMPUTED TOMOGRAPHY, LUMBAR SPINE; WITHOUT CONTRAST MATERIAL" 9512896_1 CDM 352 RC 72131 HCPCS outpatient 1810 1357.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1610.9 89 999999999 1411.8 1719.5 percent of total billed charges "COMPUTED TOMOGRAPHY, LUMBAR SPINE; WITHOUT CONTRAST MATERIAL" 9512896_1 CDM 352 RC 72131 HCPCS outpatient 1810 1357.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1610.9 89 999999999 1411.8 1719.5 percent of total billed charges "COMPUTED TOMOGRAPHY, LUMBAR SPINE; WITHOUT CONTRAST MATERIAL" 9512896_1 CDM 352 RC 72131 HCPCS outpatient 1810 1357.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1629 90 999999999 1411.8 1719.5 percent of total billed charges "COMPUTED TOMOGRAPHY, LUMBAR SPINE; WITHOUT CONTRAST MATERIAL" 9512896_1 CDM 352 RC 72131 HCPCS outpatient 1810 1357.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1719.5 95 999999999 1411.8 1719.5 percent of total billed charges "COMPUTED TOMOGRAPHY, LUMBAR SPINE; WITHOUT CONTRAST MATERIAL" 9512896_1 CDM 352 RC 72131 HCPCS outpatient 1810 1357.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1719.5 95 999999999 1411.8 1719.5 percent of total billed charges "COMPUTED TOMOGRAPHY, LUMBAR SPINE; WITHOUT CONTRAST MATERIAL" 9512896_1 CDM 352 RC 72131 HCPCS outpatient 1810 1357.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1610.9 89 999999999 1411.8 1719.5 percent of total billed charges "COMPUTED TOMOGRAPHY, LUMBAR SPINE; WITHOUT CONTRAST MATERIAL" 9512896_1 CDM 352 RC 72131 HCPCS outpatient 1810 1357.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1592.8 88 999999999 1411.8 1719.5 percent of total billed charges "COMPUTED TOMOGRAPHY, LUMBAR SPINE; WITHOUT CONTRAST MATERIAL" 9512896_1 CDM 352 RC 72131 HCPCS outpatient 1810 1357.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1610.9 89 999999999 1411.8 1719.5 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, CERVICAL; WITHOUT CONTRAST MATERIAL" 9512905_1 CDM 612 RC 72141 HCPCS outpatient 2315 1736.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 2083.5 90 999999999 1805.7 2199.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, CERVICAL; WITHOUT CONTRAST MATERIAL" 9512905_1 CDM 612 RC 72141 HCPCS outpatient 2315 1736.25 AETNA MCR ADV AETNA MCR ADV 1805.7 78 999999999 1805.7 2199.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, CERVICAL; WITHOUT CONTRAST MATERIAL" 9512905_1 CDM 612 RC 72141 HCPCS outpatient 2315 1736.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 2027.25 87.57 999999999 1805.7 2199.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, CERVICAL; WITHOUT CONTRAST MATERIAL" 9512905_1 CDM 612 RC 72141 HCPCS outpatient 2315 1736.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 1969.37 85.07 999999999 1805.7 2199.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, CERVICAL; WITHOUT CONTRAST MATERIAL" 9512905_1 CDM 612 RC 72141 HCPCS outpatient 2315 1736.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1969.37 85.07 999999999 1805.7 2199.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, CERVICAL; WITHOUT CONTRAST MATERIAL" 9512905_1 CDM 612 RC 72141 HCPCS outpatient 2315 1736.25 MOLINA MCAID MOLINA MCAID 1930.71 83.4 999999999 1805.7 2199.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, CERVICAL; WITHOUT CONTRAST MATERIAL" 9512905_1 CDM 612 RC 72141 HCPCS outpatient 2315 1736.25 MOLINA MCR ADV MOLINA MCR ADV 2060.35 89 999999999 1805.7 2199.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, CERVICAL; WITHOUT CONTRAST MATERIAL" 9512905_1 CDM 612 RC 72141 HCPCS outpatient 2315 1736.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 2060.35 89 999999999 1805.7 2199.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, CERVICAL; WITHOUT CONTRAST MATERIAL" 9512905_1 CDM 612 RC 72141 HCPCS outpatient 2315 1736.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 2060.35 89 999999999 1805.7 2199.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, CERVICAL; WITHOUT CONTRAST MATERIAL" 9512905_1 CDM 612 RC 72141 HCPCS outpatient 2315 1736.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 2083.5 90 999999999 1805.7 2199.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, CERVICAL; WITHOUT CONTRAST MATERIAL" 9512905_1 CDM 612 RC 72141 HCPCS outpatient 2315 1736.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 2199.25 95 999999999 1805.7 2199.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, CERVICAL; WITHOUT CONTRAST MATERIAL" 9512905_1 CDM 612 RC 72141 HCPCS outpatient 2315 1736.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 2199.25 95 999999999 1805.7 2199.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, CERVICAL; WITHOUT CONTRAST MATERIAL" 9512905_1 CDM 612 RC 72141 HCPCS outpatient 2315 1736.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 2060.35 89 999999999 1805.7 2199.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, CERVICAL; WITHOUT CONTRAST MATERIAL" 9512905_1 CDM 612 RC 72141 HCPCS outpatient 2315 1736.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 2037.2 88 999999999 1805.7 2199.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, CERVICAL; WITHOUT CONTRAST MATERIAL" 9512905_1 CDM 612 RC 72141 HCPCS outpatient 2315 1736.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 2060.35 89 999999999 1805.7 2199.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, THORACIC; WITHOUT CONTRAST MATERIAL" 9512911_1 CDM 612 RC 72146 HCPCS outpatient 2583 1937.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 2324.7 90 999999999 2014.74 2453.85 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, THORACIC; WITHOUT CONTRAST MATERIAL" 9512911_1 CDM 612 RC 72146 HCPCS outpatient 2583 1937.25 AETNA MCR ADV AETNA MCR ADV 2014.74 78 999999999 2014.74 2453.85 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, THORACIC; WITHOUT CONTRAST MATERIAL" 9512911_1 CDM 612 RC 72146 HCPCS outpatient 2583 1937.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 2261.93 87.57 999999999 2014.74 2453.85 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, THORACIC; WITHOUT CONTRAST MATERIAL" 9512911_1 CDM 612 RC 72146 HCPCS outpatient 2583 1937.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 2197.36 85.07 999999999 2014.74 2453.85 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, THORACIC; WITHOUT CONTRAST MATERIAL" 9512911_1 CDM 612 RC 72146 HCPCS outpatient 2583 1937.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 2197.36 85.07 999999999 2014.74 2453.85 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, THORACIC; WITHOUT CONTRAST MATERIAL" 9512911_1 CDM 612 RC 72146 HCPCS outpatient 2583 1937.25 MOLINA MCAID MOLINA MCAID 2154.22 83.4 999999999 2014.74 2453.85 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, THORACIC; WITHOUT CONTRAST MATERIAL" 9512911_1 CDM 612 RC 72146 HCPCS outpatient 2583 1937.25 MOLINA MCR ADV MOLINA MCR ADV 2298.87 89 999999999 2014.74 2453.85 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, THORACIC; WITHOUT CONTRAST MATERIAL" 9512911_1 CDM 612 RC 72146 HCPCS outpatient 2583 1937.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 2298.87 89 999999999 2014.74 2453.85 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, THORACIC; WITHOUT CONTRAST MATERIAL" 9512911_1 CDM 612 RC 72146 HCPCS outpatient 2583 1937.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 2298.87 89 999999999 2014.74 2453.85 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, THORACIC; WITHOUT CONTRAST MATERIAL" 9512911_1 CDM 612 RC 72146 HCPCS outpatient 2583 1937.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 2324.7 90 999999999 2014.74 2453.85 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, THORACIC; WITHOUT CONTRAST MATERIAL" 9512911_1 CDM 612 RC 72146 HCPCS outpatient 2583 1937.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 2453.85 95 999999999 2014.74 2453.85 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, THORACIC; WITHOUT CONTRAST MATERIAL" 9512911_1 CDM 612 RC 72146 HCPCS outpatient 2583 1937.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 2453.85 95 999999999 2014.74 2453.85 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, THORACIC; WITHOUT CONTRAST MATERIAL" 9512911_1 CDM 612 RC 72146 HCPCS outpatient 2583 1937.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 2298.87 89 999999999 2014.74 2453.85 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, THORACIC; WITHOUT CONTRAST MATERIAL" 9512911_1 CDM 612 RC 72146 HCPCS outpatient 2583 1937.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 2273.04 88 999999999 2014.74 2453.85 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, THORACIC; WITHOUT CONTRAST MATERIAL" 9512911_1 CDM 612 RC 72146 HCPCS outpatient 2583 1937.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 2298.87 89 999999999 2014.74 2453.85 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, LUMBAR; WITHOUT CONTRAST MATERIAL" 9512917_1 CDM 612 RC 72148 HCPCS outpatient 2441 1830.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 2196.9 90 999999999 1903.98 2318.95 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, LUMBAR; WITHOUT CONTRAST MATERIAL" 9512917_1 CDM 612 RC 72148 HCPCS outpatient 2441 1830.75 AETNA MCR ADV AETNA MCR ADV 1903.98 78 999999999 1903.98 2318.95 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, LUMBAR; WITHOUT CONTRAST MATERIAL" 9512917_1 CDM 612 RC 72148 HCPCS outpatient 2441 1830.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 2137.58 87.57 999999999 1903.98 2318.95 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, LUMBAR; WITHOUT CONTRAST MATERIAL" 9512917_1 CDM 612 RC 72148 HCPCS outpatient 2441 1830.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 2076.56 85.07 999999999 1903.98 2318.95 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, LUMBAR; WITHOUT CONTRAST MATERIAL" 9512917_1 CDM 612 RC 72148 HCPCS outpatient 2441 1830.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 2076.56 85.07 999999999 1903.98 2318.95 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, LUMBAR; WITHOUT CONTRAST MATERIAL" 9512917_1 CDM 612 RC 72148 HCPCS outpatient 2441 1830.75 MOLINA MCAID MOLINA MCAID 2035.79 83.4 999999999 1903.98 2318.95 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, LUMBAR; WITHOUT CONTRAST MATERIAL" 9512917_1 CDM 612 RC 72148 HCPCS outpatient 2441 1830.75 MOLINA MCR ADV MOLINA MCR ADV 2172.49 89 999999999 1903.98 2318.95 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, LUMBAR; WITHOUT CONTRAST MATERIAL" 9512917_1 CDM 612 RC 72148 HCPCS outpatient 2441 1830.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 2172.49 89 999999999 1903.98 2318.95 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, LUMBAR; WITHOUT CONTRAST MATERIAL" 9512917_1 CDM 612 RC 72148 HCPCS outpatient 2441 1830.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 2172.49 89 999999999 1903.98 2318.95 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, LUMBAR; WITHOUT CONTRAST MATERIAL" 9512917_1 CDM 612 RC 72148 HCPCS outpatient 2441 1830.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 2196.9 90 999999999 1903.98 2318.95 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, LUMBAR; WITHOUT CONTRAST MATERIAL" 9512917_1 CDM 612 RC 72148 HCPCS outpatient 2441 1830.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 2318.95 95 999999999 1903.98 2318.95 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, LUMBAR; WITHOUT CONTRAST MATERIAL" 9512917_1 CDM 612 RC 72148 HCPCS outpatient 2441 1830.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 2318.95 95 999999999 1903.98 2318.95 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, LUMBAR; WITHOUT CONTRAST MATERIAL" 9512917_1 CDM 612 RC 72148 HCPCS outpatient 2441 1830.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 2172.49 89 999999999 1903.98 2318.95 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, LUMBAR; WITHOUT CONTRAST MATERIAL" 9512917_1 CDM 612 RC 72148 HCPCS outpatient 2441 1830.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 2148.08 88 999999999 1903.98 2318.95 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, LUMBAR; WITHOUT CONTRAST MATERIAL" 9512917_1 CDM 612 RC 72148 HCPCS outpatient 2441 1830.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 2172.49 89 999999999 1903.98 2318.95 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; CERVICAL" 9512923_1 CDM 612 RC 72156 HCPCS outpatient 3718 2788.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 3346.2 90 999999999 2900.04 3532.1 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; CERVICAL" 9512923_1 CDM 612 RC 72156 HCPCS outpatient 3718 2788.5 AETNA MCR ADV AETNA MCR ADV 2900.04 78 999999999 2900.04 3532.1 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; CERVICAL" 9512923_1 CDM 612 RC 72156 HCPCS outpatient 3718 2788.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 3255.85 87.57 999999999 2900.04 3532.1 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; CERVICAL" 9512923_1 CDM 612 RC 72156 HCPCS outpatient 3718 2788.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 3162.9 85.07 999999999 2900.04 3532.1 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; CERVICAL" 9512923_1 CDM 612 RC 72156 HCPCS outpatient 3718 2788.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 3162.9 85.07 999999999 2900.04 3532.1 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; CERVICAL" 9512923_1 CDM 612 RC 72156 HCPCS outpatient 3718 2788.5 MOLINA MCAID MOLINA MCAID 3100.81 83.4 999999999 2900.04 3532.1 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; CERVICAL" 9512923_1 CDM 612 RC 72156 HCPCS outpatient 3718 2788.5 MOLINA MCR ADV MOLINA MCR ADV 3309.02 89 999999999 2900.04 3532.1 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; CERVICAL" 9512923_1 CDM 612 RC 72156 HCPCS outpatient 3718 2788.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 3309.02 89 999999999 2900.04 3532.1 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; CERVICAL" 9512923_1 CDM 612 RC 72156 HCPCS outpatient 3718 2788.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 3309.02 89 999999999 2900.04 3532.1 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; CERVICAL" 9512923_1 CDM 612 RC 72156 HCPCS outpatient 3718 2788.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 3346.2 90 999999999 2900.04 3532.1 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; CERVICAL" 9512923_1 CDM 612 RC 72156 HCPCS outpatient 3718 2788.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 3532.1 95 999999999 2900.04 3532.1 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; CERVICAL" 9512923_1 CDM 612 RC 72156 HCPCS outpatient 3718 2788.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 3532.1 95 999999999 2900.04 3532.1 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; CERVICAL" 9512923_1 CDM 612 RC 72156 HCPCS outpatient 3718 2788.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 3309.02 89 999999999 2900.04 3532.1 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; CERVICAL" 9512923_1 CDM 612 RC 72156 HCPCS outpatient 3718 2788.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 3271.84 88 999999999 2900.04 3532.1 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; CERVICAL" 9512923_1 CDM 612 RC 72156 HCPCS outpatient 3718 2788.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 3309.02 89 999999999 2900.04 3532.1 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; THORACIC" 9512926_1 CDM 612 RC 72157 HCPCS outpatient 3619 2714.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 3257.1 90 999999999 2822.82 3438.05 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; THORACIC" 9512926_1 CDM 612 RC 72157 HCPCS outpatient 3619 2714.25 AETNA MCR ADV AETNA MCR ADV 2822.82 78 999999999 2822.82 3438.05 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; THORACIC" 9512926_1 CDM 612 RC 72157 HCPCS outpatient 3619 2714.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 3169.16 87.57 999999999 2822.82 3438.05 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; THORACIC" 9512926_1 CDM 612 RC 72157 HCPCS outpatient 3619 2714.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 3078.68 85.07 999999999 2822.82 3438.05 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; THORACIC" 9512926_1 CDM 612 RC 72157 HCPCS outpatient 3619 2714.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 3078.68 85.07 999999999 2822.82 3438.05 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; THORACIC" 9512926_1 CDM 612 RC 72157 HCPCS outpatient 3619 2714.25 MOLINA MCAID MOLINA MCAID 3018.25 83.4 999999999 2822.82 3438.05 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; THORACIC" 9512926_1 CDM 612 RC 72157 HCPCS outpatient 3619 2714.25 MOLINA MCR ADV MOLINA MCR ADV 3220.91 89 999999999 2822.82 3438.05 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; THORACIC" 9512926_1 CDM 612 RC 72157 HCPCS outpatient 3619 2714.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 3220.91 89 999999999 2822.82 3438.05 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; THORACIC" 9512926_1 CDM 612 RC 72157 HCPCS outpatient 3619 2714.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 3220.91 89 999999999 2822.82 3438.05 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; THORACIC" 9512926_1 CDM 612 RC 72157 HCPCS outpatient 3619 2714.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 3257.1 90 999999999 2822.82 3438.05 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; THORACIC" 9512926_1 CDM 612 RC 72157 HCPCS outpatient 3619 2714.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 3438.05 95 999999999 2822.82 3438.05 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; THORACIC" 9512926_1 CDM 612 RC 72157 HCPCS outpatient 3619 2714.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 3438.05 95 999999999 2822.82 3438.05 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; THORACIC" 9512926_1 CDM 612 RC 72157 HCPCS outpatient 3619 2714.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 3220.91 89 999999999 2822.82 3438.05 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; THORACIC" 9512926_1 CDM 612 RC 72157 HCPCS outpatient 3619 2714.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 3184.72 88 999999999 2822.82 3438.05 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; THORACIC" 9512926_1 CDM 612 RC 72157 HCPCS outpatient 3619 2714.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 3220.91 89 999999999 2822.82 3438.05 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; LUMBAR" 9512929_1 CDM 612 RC 72158 HCPCS outpatient 3684 2763 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 3315.6 90 999999999 2873.52 3499.8 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; LUMBAR" 9512929_1 CDM 612 RC 72158 HCPCS outpatient 3684 2763 AETNA MCR ADV AETNA MCR ADV 2873.52 78 999999999 2873.52 3499.8 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; LUMBAR" 9512929_1 CDM 612 RC 72158 HCPCS outpatient 3684 2763 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 3226.08 87.57 999999999 2873.52 3499.8 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; LUMBAR" 9512929_1 CDM 612 RC 72158 HCPCS outpatient 3684 2763 COORDINATED CARE MCAID COORDINATED CARE MCAID 3133.98 85.07 999999999 2873.52 3499.8 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; LUMBAR" 9512929_1 CDM 612 RC 72158 HCPCS outpatient 3684 2763 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 3133.98 85.07 999999999 2873.52 3499.8 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; LUMBAR" 9512929_1 CDM 612 RC 72158 HCPCS outpatient 3684 2763 MOLINA MCAID MOLINA MCAID 3072.46 83.4 999999999 2873.52 3499.8 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; LUMBAR" 9512929_1 CDM 612 RC 72158 HCPCS outpatient 3684 2763 MOLINA MCR ADV MOLINA MCR ADV 3278.76 89 999999999 2873.52 3499.8 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; LUMBAR" 9512929_1 CDM 612 RC 72158 HCPCS outpatient 3684 2763 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 3278.76 89 999999999 2873.52 3499.8 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; LUMBAR" 9512929_1 CDM 612 RC 72158 HCPCS outpatient 3684 2763 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 3278.76 89 999999999 2873.52 3499.8 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; LUMBAR" 9512929_1 CDM 612 RC 72158 HCPCS outpatient 3684 2763 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 3315.6 90 999999999 2873.52 3499.8 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; LUMBAR" 9512929_1 CDM 612 RC 72158 HCPCS outpatient 3684 2763 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 3499.8 95 999999999 2873.52 3499.8 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; LUMBAR" 9512929_1 CDM 612 RC 72158 HCPCS outpatient 3684 2763 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 3499.8 95 999999999 2873.52 3499.8 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; LUMBAR" 9512929_1 CDM 612 RC 72158 HCPCS outpatient 3684 2763 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 3278.76 89 999999999 2873.52 3499.8 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; LUMBAR" 9512929_1 CDM 612 RC 72158 HCPCS outpatient 3684 2763 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 3241.92 88 999999999 2873.52 3499.8 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; LUMBAR" 9512929_1 CDM 612 RC 72158 HCPCS outpatient 3684 2763 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 3278.76 89 999999999 2873.52 3499.8 percent of total billed charges "RADIOLOGIC EXAMINATION, PELVIS; 1 OR 2 VIEWS" 9512935_1 CDM 320 RC 72170 HCPCS outpatient 268 201 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 241.2 90 999999999 209.04 254.6 percent of total billed charges "RADIOLOGIC EXAMINATION, PELVIS; 1 OR 2 VIEWS" 9512935_1 CDM 320 RC 72170 HCPCS outpatient 268 201 AETNA MCR ADV AETNA MCR ADV 209.04 78 999999999 209.04 254.6 percent of total billed charges "RADIOLOGIC EXAMINATION, PELVIS; 1 OR 2 VIEWS" 9512935_1 CDM 320 RC 72170 HCPCS outpatient 268 201 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 234.69 87.57 999999999 209.04 254.6 percent of total billed charges "RADIOLOGIC EXAMINATION, PELVIS; 1 OR 2 VIEWS" 9512935_1 CDM 320 RC 72170 HCPCS outpatient 268 201 COORDINATED CARE MCAID COORDINATED CARE MCAID 227.99 85.07 999999999 209.04 254.6 percent of total billed charges "RADIOLOGIC EXAMINATION, PELVIS; 1 OR 2 VIEWS" 9512935_1 CDM 320 RC 72170 HCPCS outpatient 268 201 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 227.99 85.07 999999999 209.04 254.6 percent of total billed charges "RADIOLOGIC EXAMINATION, PELVIS; 1 OR 2 VIEWS" 9512935_1 CDM 320 RC 72170 HCPCS outpatient 268 201 MOLINA MCAID MOLINA MCAID 223.51 83.4 999999999 209.04 254.6 percent of total billed charges "RADIOLOGIC EXAMINATION, PELVIS; 1 OR 2 VIEWS" 9512935_1 CDM 320 RC 72170 HCPCS outpatient 268 201 MOLINA MCR ADV MOLINA MCR ADV 238.52 89 999999999 209.04 254.6 percent of total billed charges "RADIOLOGIC EXAMINATION, PELVIS; 1 OR 2 VIEWS" 9512935_1 CDM 320 RC 72170 HCPCS outpatient 268 201 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 238.52 89 999999999 209.04 254.6 percent of total billed charges "RADIOLOGIC EXAMINATION, PELVIS; 1 OR 2 VIEWS" 9512935_1 CDM 320 RC 72170 HCPCS outpatient 268 201 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 238.52 89 999999999 209.04 254.6 percent of total billed charges "RADIOLOGIC EXAMINATION, PELVIS; 1 OR 2 VIEWS" 9512935_1 CDM 320 RC 72170 HCPCS outpatient 268 201 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 241.2 90 999999999 209.04 254.6 percent of total billed charges "RADIOLOGIC EXAMINATION, PELVIS; 1 OR 2 VIEWS" 9512935_1 CDM 320 RC 72170 HCPCS outpatient 268 201 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 254.6 95 999999999 209.04 254.6 percent of total billed charges "RADIOLOGIC EXAMINATION, PELVIS; 1 OR 2 VIEWS" 9512935_1 CDM 320 RC 72170 HCPCS outpatient 268 201 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 254.6 95 999999999 209.04 254.6 percent of total billed charges "RADIOLOGIC EXAMINATION, PELVIS; 1 OR 2 VIEWS" 9512935_1 CDM 320 RC 72170 HCPCS outpatient 268 201 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 238.52 89 999999999 209.04 254.6 percent of total billed charges "RADIOLOGIC EXAMINATION, PELVIS; 1 OR 2 VIEWS" 9512935_1 CDM 320 RC 72170 HCPCS outpatient 268 201 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 235.84 88 999999999 209.04 254.6 percent of total billed charges "RADIOLOGIC EXAMINATION, PELVIS; 1 OR 2 VIEWS" 9512935_1 CDM 320 RC 72170 HCPCS outpatient 268 201 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 238.52 89 999999999 209.04 254.6 percent of total billed charges "RADIOLOGIC EXAMINATION, PELVIS; COMPLETE, MINIMUM OF 3 VIEWS" 9512938_1 CDM 320 RC 72190 HCPCS outpatient 370 277.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 333 90 999999999 288.6 351.5 percent of total billed charges "RADIOLOGIC EXAMINATION, PELVIS; COMPLETE, MINIMUM OF 3 VIEWS" 9512938_1 CDM 320 RC 72190 HCPCS outpatient 370 277.5 AETNA MCR ADV AETNA MCR ADV 288.6 78 999999999 288.6 351.5 percent of total billed charges "RADIOLOGIC EXAMINATION, PELVIS; COMPLETE, MINIMUM OF 3 VIEWS" 9512938_1 CDM 320 RC 72190 HCPCS outpatient 370 277.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 324.01 87.57 999999999 288.6 351.5 percent of total billed charges "RADIOLOGIC EXAMINATION, PELVIS; COMPLETE, MINIMUM OF 3 VIEWS" 9512938_1 CDM 320 RC 72190 HCPCS outpatient 370 277.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 314.76 85.07 999999999 288.6 351.5 percent of total billed charges "RADIOLOGIC EXAMINATION, PELVIS; COMPLETE, MINIMUM OF 3 VIEWS" 9512938_1 CDM 320 RC 72190 HCPCS outpatient 370 277.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 314.76 85.07 999999999 288.6 351.5 percent of total billed charges "RADIOLOGIC EXAMINATION, PELVIS; COMPLETE, MINIMUM OF 3 VIEWS" 9512938_1 CDM 320 RC 72190 HCPCS outpatient 370 277.5 MOLINA MCAID MOLINA MCAID 308.58 83.4 999999999 288.6 351.5 percent of total billed charges "RADIOLOGIC EXAMINATION, PELVIS; COMPLETE, MINIMUM OF 3 VIEWS" 9512938_1 CDM 320 RC 72190 HCPCS outpatient 370 277.5 MOLINA MCR ADV MOLINA MCR ADV 329.3 89 999999999 288.6 351.5 percent of total billed charges "RADIOLOGIC EXAMINATION, PELVIS; COMPLETE, MINIMUM OF 3 VIEWS" 9512938_1 CDM 320 RC 72190 HCPCS outpatient 370 277.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 329.3 89 999999999 288.6 351.5 percent of total billed charges "RADIOLOGIC EXAMINATION, PELVIS; COMPLETE, MINIMUM OF 3 VIEWS" 9512938_1 CDM 320 RC 72190 HCPCS outpatient 370 277.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 329.3 89 999999999 288.6 351.5 percent of total billed charges "RADIOLOGIC EXAMINATION, PELVIS; COMPLETE, MINIMUM OF 3 VIEWS" 9512938_1 CDM 320 RC 72190 HCPCS outpatient 370 277.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 333 90 999999999 288.6 351.5 percent of total billed charges "RADIOLOGIC EXAMINATION, PELVIS; COMPLETE, MINIMUM OF 3 VIEWS" 9512938_1 CDM 320 RC 72190 HCPCS outpatient 370 277.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 351.5 95 999999999 288.6 351.5 percent of total billed charges "RADIOLOGIC EXAMINATION, PELVIS; COMPLETE, MINIMUM OF 3 VIEWS" 9512938_1 CDM 320 RC 72190 HCPCS outpatient 370 277.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 351.5 95 999999999 288.6 351.5 percent of total billed charges "RADIOLOGIC EXAMINATION, PELVIS; COMPLETE, MINIMUM OF 3 VIEWS" 9512938_1 CDM 320 RC 72190 HCPCS outpatient 370 277.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 329.3 89 999999999 288.6 351.5 percent of total billed charges "RADIOLOGIC EXAMINATION, PELVIS; COMPLETE, MINIMUM OF 3 VIEWS" 9512938_1 CDM 320 RC 72190 HCPCS outpatient 370 277.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 325.6 88 999999999 288.6 351.5 percent of total billed charges "RADIOLOGIC EXAMINATION, PELVIS; COMPLETE, MINIMUM OF 3 VIEWS" 9512938_1 CDM 320 RC 72190 HCPCS outpatient 370 277.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 329.3 89 999999999 288.6 351.5 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL" 9512944_1 CDM 352 RC 72192 HCPCS outpatient 1602 1201.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1441.8 90 999999999 1249.56 1521.9 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL" 9512944_1 CDM 352 RC 72192 HCPCS outpatient 1602 1201.5 AETNA MCR ADV AETNA MCR ADV 1249.56 78 999999999 1249.56 1521.9 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL" 9512944_1 CDM 352 RC 72192 HCPCS outpatient 1602 1201.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1402.87 87.57 999999999 1249.56 1521.9 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL" 9512944_1 CDM 352 RC 72192 HCPCS outpatient 1602 1201.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 1362.82 85.07 999999999 1249.56 1521.9 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL" 9512944_1 CDM 352 RC 72192 HCPCS outpatient 1602 1201.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1362.82 85.07 999999999 1249.56 1521.9 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL" 9512944_1 CDM 352 RC 72192 HCPCS outpatient 1602 1201.5 MOLINA MCAID MOLINA MCAID 1336.07 83.4 999999999 1249.56 1521.9 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL" 9512944_1 CDM 352 RC 72192 HCPCS outpatient 1602 1201.5 MOLINA MCR ADV MOLINA MCR ADV 1425.78 89 999999999 1249.56 1521.9 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL" 9512944_1 CDM 352 RC 72192 HCPCS outpatient 1602 1201.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1425.78 89 999999999 1249.56 1521.9 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL" 9512944_1 CDM 352 RC 72192 HCPCS outpatient 1602 1201.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1425.78 89 999999999 1249.56 1521.9 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL" 9512944_1 CDM 352 RC 72192 HCPCS outpatient 1602 1201.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1441.8 90 999999999 1249.56 1521.9 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL" 9512944_1 CDM 352 RC 72192 HCPCS outpatient 1602 1201.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1521.9 95 999999999 1249.56 1521.9 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL" 9512944_1 CDM 352 RC 72192 HCPCS outpatient 1602 1201.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1521.9 95 999999999 1249.56 1521.9 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL" 9512944_1 CDM 352 RC 72192 HCPCS outpatient 1602 1201.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1425.78 89 999999999 1249.56 1521.9 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL" 9512944_1 CDM 352 RC 72192 HCPCS outpatient 1602 1201.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1409.76 88 999999999 1249.56 1521.9 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL" 9512944_1 CDM 352 RC 72192 HCPCS outpatient 1602 1201.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1425.78 89 999999999 1249.56 1521.9 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITH CONTRAST MATERIAL(S)" 9512947_1 CDM 352 RC 72193 HCPCS outpatient 2273 1704.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 2045.7 90 999999999 1772.94 2159.35 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITH CONTRAST MATERIAL(S)" 9512947_1 CDM 352 RC 72193 HCPCS outpatient 2273 1704.75 AETNA MCR ADV AETNA MCR ADV 1772.94 78 999999999 1772.94 2159.35 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITH CONTRAST MATERIAL(S)" 9512947_1 CDM 352 RC 72193 HCPCS outpatient 2273 1704.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1990.47 87.57 999999999 1772.94 2159.35 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITH CONTRAST MATERIAL(S)" 9512947_1 CDM 352 RC 72193 HCPCS outpatient 2273 1704.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 1933.64 85.07 999999999 1772.94 2159.35 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITH CONTRAST MATERIAL(S)" 9512947_1 CDM 352 RC 72193 HCPCS outpatient 2273 1704.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1933.64 85.07 999999999 1772.94 2159.35 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITH CONTRAST MATERIAL(S)" 9512947_1 CDM 352 RC 72193 HCPCS outpatient 2273 1704.75 MOLINA MCAID MOLINA MCAID 1895.68 83.4 999999999 1772.94 2159.35 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITH CONTRAST MATERIAL(S)" 9512947_1 CDM 352 RC 72193 HCPCS outpatient 2273 1704.75 MOLINA MCR ADV MOLINA MCR ADV 2022.97 89 999999999 1772.94 2159.35 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITH CONTRAST MATERIAL(S)" 9512947_1 CDM 352 RC 72193 HCPCS outpatient 2273 1704.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 2022.97 89 999999999 1772.94 2159.35 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITH CONTRAST MATERIAL(S)" 9512947_1 CDM 352 RC 72193 HCPCS outpatient 2273 1704.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 2022.97 89 999999999 1772.94 2159.35 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITH CONTRAST MATERIAL(S)" 9512947_1 CDM 352 RC 72193 HCPCS outpatient 2273 1704.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 2045.7 90 999999999 1772.94 2159.35 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITH CONTRAST MATERIAL(S)" 9512947_1 CDM 352 RC 72193 HCPCS outpatient 2273 1704.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 2159.35 95 999999999 1772.94 2159.35 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITH CONTRAST MATERIAL(S)" 9512947_1 CDM 352 RC 72193 HCPCS outpatient 2273 1704.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 2159.35 95 999999999 1772.94 2159.35 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITH CONTRAST MATERIAL(S)" 9512947_1 CDM 352 RC 72193 HCPCS outpatient 2273 1704.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 2022.97 89 999999999 1772.94 2159.35 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITH CONTRAST MATERIAL(S)" 9512947_1 CDM 352 RC 72193 HCPCS outpatient 2273 1704.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 2000.24 88 999999999 1772.94 2159.35 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITH CONTRAST MATERIAL(S)" 9512947_1 CDM 352 RC 72193 HCPCS outpatient 2273 1704.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 2022.97 89 999999999 1772.94 2159.35 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512950_1 CDM 352 RC 72194 HCPCS outpatient 3002 2251.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 2701.8 90 999999999 2341.56 2851.9 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512950_1 CDM 352 RC 72194 HCPCS outpatient 3002 2251.5 AETNA MCR ADV AETNA MCR ADV 2341.56 78 999999999 2341.56 2851.9 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512950_1 CDM 352 RC 72194 HCPCS outpatient 3002 2251.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 2628.85 87.57 999999999 2341.56 2851.9 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512950_1 CDM 352 RC 72194 HCPCS outpatient 3002 2251.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 2553.8 85.07 999999999 2341.56 2851.9 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512950_1 CDM 352 RC 72194 HCPCS outpatient 3002 2251.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 2553.8 85.07 999999999 2341.56 2851.9 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512950_1 CDM 352 RC 72194 HCPCS outpatient 3002 2251.5 MOLINA MCAID MOLINA MCAID 2503.67 83.4 999999999 2341.56 2851.9 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512950_1 CDM 352 RC 72194 HCPCS outpatient 3002 2251.5 MOLINA MCR ADV MOLINA MCR ADV 2671.78 89 999999999 2341.56 2851.9 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512950_1 CDM 352 RC 72194 HCPCS outpatient 3002 2251.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 2671.78 89 999999999 2341.56 2851.9 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512950_1 CDM 352 RC 72194 HCPCS outpatient 3002 2251.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 2671.78 89 999999999 2341.56 2851.9 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512950_1 CDM 352 RC 72194 HCPCS outpatient 3002 2251.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 2701.8 90 999999999 2341.56 2851.9 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512950_1 CDM 352 RC 72194 HCPCS outpatient 3002 2251.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 2851.9 95 999999999 2341.56 2851.9 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512950_1 CDM 352 RC 72194 HCPCS outpatient 3002 2251.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 2851.9 95 999999999 2341.56 2851.9 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512950_1 CDM 352 RC 72194 HCPCS outpatient 3002 2251.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 2671.78 89 999999999 2341.56 2851.9 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512950_1 CDM 352 RC 72194 HCPCS outpatient 3002 2251.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 2641.76 88 999999999 2341.56 2851.9 percent of total billed charges "COMPUTED TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9512950_1 CDM 352 RC 72194 HCPCS outpatient 3002 2251.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 2671.78 89 999999999 2341.56 2851.9 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITHOUT CONTRAST MATERIAL(S)" 9512953_1 CDM 610 RC 72195 HCPCS outpatient 2730 2047.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 2457 90 999999999 2129.4 2593.5 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITHOUT CONTRAST MATERIAL(S)" 9512953_1 CDM 610 RC 72195 HCPCS outpatient 2730 2047.5 AETNA MCR ADV AETNA MCR ADV 2129.4 78 999999999 2129.4 2593.5 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITHOUT CONTRAST MATERIAL(S)" 9512953_1 CDM 610 RC 72195 HCPCS outpatient 2730 2047.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 2390.66 87.57 999999999 2129.4 2593.5 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITHOUT CONTRAST MATERIAL(S)" 9512953_1 CDM 610 RC 72195 HCPCS outpatient 2730 2047.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 2322.41 85.07 999999999 2129.4 2593.5 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITHOUT CONTRAST MATERIAL(S)" 9512953_1 CDM 610 RC 72195 HCPCS outpatient 2730 2047.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 2322.41 85.07 999999999 2129.4 2593.5 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITHOUT CONTRAST MATERIAL(S)" 9512953_1 CDM 610 RC 72195 HCPCS outpatient 2730 2047.5 MOLINA MCAID MOLINA MCAID 2276.82 83.4 999999999 2129.4 2593.5 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITHOUT CONTRAST MATERIAL(S)" 9512953_1 CDM 610 RC 72195 HCPCS outpatient 2730 2047.5 MOLINA MCR ADV MOLINA MCR ADV 2429.7 89 999999999 2129.4 2593.5 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITHOUT CONTRAST MATERIAL(S)" 9512953_1 CDM 610 RC 72195 HCPCS outpatient 2730 2047.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 2429.7 89 999999999 2129.4 2593.5 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITHOUT CONTRAST MATERIAL(S)" 9512953_1 CDM 610 RC 72195 HCPCS outpatient 2730 2047.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 2429.7 89 999999999 2129.4 2593.5 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITHOUT CONTRAST MATERIAL(S)" 9512953_1 CDM 610 RC 72195 HCPCS outpatient 2730 2047.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 2457 90 999999999 2129.4 2593.5 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITHOUT CONTRAST MATERIAL(S)" 9512953_1 CDM 610 RC 72195 HCPCS outpatient 2730 2047.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 2593.5 95 999999999 2129.4 2593.5 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITHOUT CONTRAST MATERIAL(S)" 9512953_1 CDM 610 RC 72195 HCPCS outpatient 2730 2047.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 2593.5 95 999999999 2129.4 2593.5 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITHOUT CONTRAST MATERIAL(S)" 9512953_1 CDM 610 RC 72195 HCPCS outpatient 2730 2047.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 2429.7 89 999999999 2129.4 2593.5 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITHOUT CONTRAST MATERIAL(S)" 9512953_1 CDM 610 RC 72195 HCPCS outpatient 2730 2047.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 2402.4 88 999999999 2129.4 2593.5 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITHOUT CONTRAST MATERIAL(S)" 9512953_1 CDM 610 RC 72195 HCPCS outpatient 2730 2047.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 2429.7 89 999999999 2129.4 2593.5 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITH CONTRAST MATERIAL(S)" 9512956_1 CDM 610 RC 72196 HCPCS outpatient 3006 2254.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 2705.4 90 999999999 2344.68 2855.7 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITH CONTRAST MATERIAL(S)" 9512956_1 CDM 610 RC 72196 HCPCS outpatient 3006 2254.5 AETNA MCR ADV AETNA MCR ADV 2344.68 78 999999999 2344.68 2855.7 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITH CONTRAST MATERIAL(S)" 9512956_1 CDM 610 RC 72196 HCPCS outpatient 3006 2254.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 2632.35 87.57 999999999 2344.68 2855.7 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITH CONTRAST MATERIAL(S)" 9512956_1 CDM 610 RC 72196 HCPCS outpatient 3006 2254.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 2557.2 85.07 999999999 2344.68 2855.7 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITH CONTRAST MATERIAL(S)" 9512956_1 CDM 610 RC 72196 HCPCS outpatient 3006 2254.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 2557.2 85.07 999999999 2344.68 2855.7 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITH CONTRAST MATERIAL(S)" 9512956_1 CDM 610 RC 72196 HCPCS outpatient 3006 2254.5 MOLINA MCAID MOLINA MCAID 2507 83.4 999999999 2344.68 2855.7 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITH CONTRAST MATERIAL(S)" 9512956_1 CDM 610 RC 72196 HCPCS outpatient 3006 2254.5 MOLINA MCR ADV MOLINA MCR ADV 2675.34 89 999999999 2344.68 2855.7 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITH CONTRAST MATERIAL(S)" 9512956_1 CDM 610 RC 72196 HCPCS outpatient 3006 2254.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 2675.34 89 999999999 2344.68 2855.7 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITH CONTRAST MATERIAL(S)" 9512956_1 CDM 610 RC 72196 HCPCS outpatient 3006 2254.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 2675.34 89 999999999 2344.68 2855.7 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITH CONTRAST MATERIAL(S)" 9512956_1 CDM 610 RC 72196 HCPCS outpatient 3006 2254.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 2705.4 90 999999999 2344.68 2855.7 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITH CONTRAST MATERIAL(S)" 9512956_1 CDM 610 RC 72196 HCPCS outpatient 3006 2254.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 2855.7 95 999999999 2344.68 2855.7 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITH CONTRAST MATERIAL(S)" 9512956_1 CDM 610 RC 72196 HCPCS outpatient 3006 2254.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 2855.7 95 999999999 2344.68 2855.7 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITH CONTRAST MATERIAL(S)" 9512956_1 CDM 610 RC 72196 HCPCS outpatient 3006 2254.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 2675.34 89 999999999 2344.68 2855.7 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITH CONTRAST MATERIAL(S)" 9512956_1 CDM 610 RC 72196 HCPCS outpatient 3006 2254.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 2645.28 88 999999999 2344.68 2855.7 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITH CONTRAST MATERIAL(S)" 9512956_1 CDM 610 RC 72196 HCPCS outpatient 3006 2254.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 2675.34 89 999999999 2344.68 2855.7 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512959_1 CDM 610 RC 72197 HCPCS outpatient 3664 2748 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 3297.6 90 999999999 2857.92 3480.8 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512959_1 CDM 610 RC 72197 HCPCS outpatient 3664 2748 AETNA MCR ADV AETNA MCR ADV 2857.92 78 999999999 2857.92 3480.8 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512959_1 CDM 610 RC 72197 HCPCS outpatient 3664 2748 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 3208.56 87.57 999999999 2857.92 3480.8 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512959_1 CDM 610 RC 72197 HCPCS outpatient 3664 2748 COORDINATED CARE MCAID COORDINATED CARE MCAID 3116.96 85.07 999999999 2857.92 3480.8 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512959_1 CDM 610 RC 72197 HCPCS outpatient 3664 2748 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 3116.96 85.07 999999999 2857.92 3480.8 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512959_1 CDM 610 RC 72197 HCPCS outpatient 3664 2748 MOLINA MCAID MOLINA MCAID 3055.78 83.4 999999999 2857.92 3480.8 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512959_1 CDM 610 RC 72197 HCPCS outpatient 3664 2748 MOLINA MCR ADV MOLINA MCR ADV 3260.96 89 999999999 2857.92 3480.8 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512959_1 CDM 610 RC 72197 HCPCS outpatient 3664 2748 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 3260.96 89 999999999 2857.92 3480.8 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512959_1 CDM 610 RC 72197 HCPCS outpatient 3664 2748 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 3260.96 89 999999999 2857.92 3480.8 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512959_1 CDM 610 RC 72197 HCPCS outpatient 3664 2748 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 3297.6 90 999999999 2857.92 3480.8 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512959_1 CDM 610 RC 72197 HCPCS outpatient 3664 2748 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 3480.8 95 999999999 2857.92 3480.8 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512959_1 CDM 610 RC 72197 HCPCS outpatient 3664 2748 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 3480.8 95 999999999 2857.92 3480.8 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512959_1 CDM 610 RC 72197 HCPCS outpatient 3664 2748 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 3260.96 89 999999999 2857.92 3480.8 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512959_1 CDM 610 RC 72197 HCPCS outpatient 3664 2748 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 3224.32 88 999999999 2857.92 3480.8 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9512959_1 CDM 610 RC 72197 HCPCS outpatient 3664 2748 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 3260.96 89 999999999 2857.92 3480.8 percent of total billed charges "RADIOLOGIC EXAMINATION, SACROILIAC JOINTS; 3 OR MORE VIEWS" 9512965_1 CDM 320 RC 72202 HCPCS outpatient 349 261.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 314.1 90 999999999 272.22 331.55 percent of total billed charges "RADIOLOGIC EXAMINATION, SACROILIAC JOINTS; 3 OR MORE VIEWS" 9512965_1 CDM 320 RC 72202 HCPCS outpatient 349 261.75 AETNA MCR ADV AETNA MCR ADV 272.22 78 999999999 272.22 331.55 percent of total billed charges "RADIOLOGIC EXAMINATION, SACROILIAC JOINTS; 3 OR MORE VIEWS" 9512965_1 CDM 320 RC 72202 HCPCS outpatient 349 261.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 305.62 87.57 999999999 272.22 331.55 percent of total billed charges "RADIOLOGIC EXAMINATION, SACROILIAC JOINTS; 3 OR MORE VIEWS" 9512965_1 CDM 320 RC 72202 HCPCS outpatient 349 261.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 296.89 85.07 999999999 272.22 331.55 percent of total billed charges "RADIOLOGIC EXAMINATION, SACROILIAC JOINTS; 3 OR MORE VIEWS" 9512965_1 CDM 320 RC 72202 HCPCS outpatient 349 261.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 296.89 85.07 999999999 272.22 331.55 percent of total billed charges "RADIOLOGIC EXAMINATION, SACROILIAC JOINTS; 3 OR MORE VIEWS" 9512965_1 CDM 320 RC 72202 HCPCS outpatient 349 261.75 MOLINA MCAID MOLINA MCAID 291.07 83.4 999999999 272.22 331.55 percent of total billed charges "RADIOLOGIC EXAMINATION, SACROILIAC JOINTS; 3 OR MORE VIEWS" 9512965_1 CDM 320 RC 72202 HCPCS outpatient 349 261.75 MOLINA MCR ADV MOLINA MCR ADV 310.61 89 999999999 272.22 331.55 percent of total billed charges "RADIOLOGIC EXAMINATION, SACROILIAC JOINTS; 3 OR MORE VIEWS" 9512965_1 CDM 320 RC 72202 HCPCS outpatient 349 261.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 310.61 89 999999999 272.22 331.55 percent of total billed charges "RADIOLOGIC EXAMINATION, SACROILIAC JOINTS; 3 OR MORE VIEWS" 9512965_1 CDM 320 RC 72202 HCPCS outpatient 349 261.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 310.61 89 999999999 272.22 331.55 percent of total billed charges "RADIOLOGIC EXAMINATION, SACROILIAC JOINTS; 3 OR MORE VIEWS" 9512965_1 CDM 320 RC 72202 HCPCS outpatient 349 261.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 314.1 90 999999999 272.22 331.55 percent of total billed charges "RADIOLOGIC EXAMINATION, SACROILIAC JOINTS; 3 OR MORE VIEWS" 9512965_1 CDM 320 RC 72202 HCPCS outpatient 349 261.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 331.55 95 999999999 272.22 331.55 percent of total billed charges "RADIOLOGIC EXAMINATION, SACROILIAC JOINTS; 3 OR MORE VIEWS" 9512965_1 CDM 320 RC 72202 HCPCS outpatient 349 261.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 331.55 95 999999999 272.22 331.55 percent of total billed charges "RADIOLOGIC EXAMINATION, SACROILIAC JOINTS; 3 OR MORE VIEWS" 9512965_1 CDM 320 RC 72202 HCPCS outpatient 349 261.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 310.61 89 999999999 272.22 331.55 percent of total billed charges "RADIOLOGIC EXAMINATION, SACROILIAC JOINTS; 3 OR MORE VIEWS" 9512965_1 CDM 320 RC 72202 HCPCS outpatient 349 261.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 307.12 88 999999999 272.22 331.55 percent of total billed charges "RADIOLOGIC EXAMINATION, SACROILIAC JOINTS; 3 OR MORE VIEWS" 9512965_1 CDM 320 RC 72202 HCPCS outpatient 349 261.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 310.61 89 999999999 272.22 331.55 percent of total billed charges "RADIOLOGIC EXAMINATION, SACRUM AND COCCYX, MINIMUM OF 2 VIEWS" 9512968_1 CDM 320 RC 72220 HCPCS outpatient 326 244.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 293.4 90 999999999 254.28 309.7 percent of total billed charges "RADIOLOGIC EXAMINATION, SACRUM AND COCCYX, MINIMUM OF 2 VIEWS" 9512968_1 CDM 320 RC 72220 HCPCS outpatient 326 244.5 AETNA MCR ADV AETNA MCR ADV 254.28 78 999999999 254.28 309.7 percent of total billed charges "RADIOLOGIC EXAMINATION, SACRUM AND COCCYX, MINIMUM OF 2 VIEWS" 9512968_1 CDM 320 RC 72220 HCPCS outpatient 326 244.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 285.48 87.57 999999999 254.28 309.7 percent of total billed charges "RADIOLOGIC EXAMINATION, SACRUM AND COCCYX, MINIMUM OF 2 VIEWS" 9512968_1 CDM 320 RC 72220 HCPCS outpatient 326 244.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 277.33 85.07 999999999 254.28 309.7 percent of total billed charges "RADIOLOGIC EXAMINATION, SACRUM AND COCCYX, MINIMUM OF 2 VIEWS" 9512968_1 CDM 320 RC 72220 HCPCS outpatient 326 244.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 277.33 85.07 999999999 254.28 309.7 percent of total billed charges "RADIOLOGIC EXAMINATION, SACRUM AND COCCYX, MINIMUM OF 2 VIEWS" 9512968_1 CDM 320 RC 72220 HCPCS outpatient 326 244.5 MOLINA MCAID MOLINA MCAID 271.88 83.4 999999999 254.28 309.7 percent of total billed charges "RADIOLOGIC EXAMINATION, SACRUM AND COCCYX, MINIMUM OF 2 VIEWS" 9512968_1 CDM 320 RC 72220 HCPCS outpatient 326 244.5 MOLINA MCR ADV MOLINA MCR ADV 290.14 89 999999999 254.28 309.7 percent of total billed charges "RADIOLOGIC EXAMINATION, SACRUM AND COCCYX, MINIMUM OF 2 VIEWS" 9512968_1 CDM 320 RC 72220 HCPCS outpatient 326 244.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 290.14 89 999999999 254.28 309.7 percent of total billed charges "RADIOLOGIC EXAMINATION, SACRUM AND COCCYX, MINIMUM OF 2 VIEWS" 9512968_1 CDM 320 RC 72220 HCPCS outpatient 326 244.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 290.14 89 999999999 254.28 309.7 percent of total billed charges "RADIOLOGIC EXAMINATION, SACRUM AND COCCYX, MINIMUM OF 2 VIEWS" 9512968_1 CDM 320 RC 72220 HCPCS outpatient 326 244.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 293.4 90 999999999 254.28 309.7 percent of total billed charges "RADIOLOGIC EXAMINATION, SACRUM AND COCCYX, MINIMUM OF 2 VIEWS" 9512968_1 CDM 320 RC 72220 HCPCS outpatient 326 244.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 309.7 95 999999999 254.28 309.7 percent of total billed charges "RADIOLOGIC EXAMINATION, SACRUM AND COCCYX, MINIMUM OF 2 VIEWS" 9512968_1 CDM 320 RC 72220 HCPCS outpatient 326 244.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 309.7 95 999999999 254.28 309.7 percent of total billed charges "RADIOLOGIC EXAMINATION, SACRUM AND COCCYX, MINIMUM OF 2 VIEWS" 9512968_1 CDM 320 RC 72220 HCPCS outpatient 326 244.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 290.14 89 999999999 254.28 309.7 percent of total billed charges "RADIOLOGIC EXAMINATION, SACRUM AND COCCYX, MINIMUM OF 2 VIEWS" 9512968_1 CDM 320 RC 72220 HCPCS outpatient 326 244.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 286.88 88 999999999 254.28 309.7 percent of total billed charges "RADIOLOGIC EXAMINATION, SACRUM AND COCCYX, MINIMUM OF 2 VIEWS" 9512968_1 CDM 320 RC 72220 HCPCS outpatient 326 244.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 290.14 89 999999999 254.28 309.7 percent of total billed charges "RADIOLOGIC EXAMINATION; CLAVICLE, COMPLETE" 9512992_1 CDM 320 RC 73000 HCPCS outpatient 286 214.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 257.4 90 999999999 223.08 271.7 percent of total billed charges "RADIOLOGIC EXAMINATION; CLAVICLE, COMPLETE" 9512992_1 CDM 320 RC 73000 HCPCS outpatient 286 214.5 AETNA MCR ADV AETNA MCR ADV 223.08 78 999999999 223.08 271.7 percent of total billed charges "RADIOLOGIC EXAMINATION; CLAVICLE, COMPLETE" 9512992_1 CDM 320 RC 73000 HCPCS outpatient 286 214.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 250.45 87.57 999999999 223.08 271.7 percent of total billed charges "RADIOLOGIC EXAMINATION; CLAVICLE, COMPLETE" 9512992_1 CDM 320 RC 73000 HCPCS outpatient 286 214.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 243.3 85.07 999999999 223.08 271.7 percent of total billed charges "RADIOLOGIC EXAMINATION; CLAVICLE, COMPLETE" 9512992_1 CDM 320 RC 73000 HCPCS outpatient 286 214.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 243.3 85.07 999999999 223.08 271.7 percent of total billed charges "RADIOLOGIC EXAMINATION; CLAVICLE, COMPLETE" 9512992_1 CDM 320 RC 73000 HCPCS outpatient 286 214.5 MOLINA MCAID MOLINA MCAID 238.52 83.4 999999999 223.08 271.7 percent of total billed charges "RADIOLOGIC EXAMINATION; CLAVICLE, COMPLETE" 9512992_1 CDM 320 RC 73000 HCPCS outpatient 286 214.5 MOLINA MCR ADV MOLINA MCR ADV 254.54 89 999999999 223.08 271.7 percent of total billed charges "RADIOLOGIC EXAMINATION; CLAVICLE, COMPLETE" 9512992_1 CDM 320 RC 73000 HCPCS outpatient 286 214.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 254.54 89 999999999 223.08 271.7 percent of total billed charges "RADIOLOGIC EXAMINATION; CLAVICLE, COMPLETE" 9512992_1 CDM 320 RC 73000 HCPCS outpatient 286 214.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 254.54 89 999999999 223.08 271.7 percent of total billed charges "RADIOLOGIC EXAMINATION; CLAVICLE, COMPLETE" 9512992_1 CDM 320 RC 73000 HCPCS outpatient 286 214.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 257.4 90 999999999 223.08 271.7 percent of total billed charges "RADIOLOGIC EXAMINATION; CLAVICLE, COMPLETE" 9512992_1 CDM 320 RC 73000 HCPCS outpatient 286 214.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 271.7 95 999999999 223.08 271.7 percent of total billed charges "RADIOLOGIC EXAMINATION; CLAVICLE, COMPLETE" 9512992_1 CDM 320 RC 73000 HCPCS outpatient 286 214.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 271.7 95 999999999 223.08 271.7 percent of total billed charges "RADIOLOGIC EXAMINATION; CLAVICLE, COMPLETE" 9512992_1 CDM 320 RC 73000 HCPCS outpatient 286 214.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 254.54 89 999999999 223.08 271.7 percent of total billed charges "RADIOLOGIC EXAMINATION; CLAVICLE, COMPLETE" 9512992_1 CDM 320 RC 73000 HCPCS outpatient 286 214.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 251.68 88 999999999 223.08 271.7 percent of total billed charges "RADIOLOGIC EXAMINATION; CLAVICLE, COMPLETE" 9512992_1 CDM 320 RC 73000 HCPCS outpatient 286 214.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 254.54 89 999999999 223.08 271.7 percent of total billed charges "RADIOLOGIC EXAMINATION; SCAPULA, COMPLETE" 9512995_1 CDM 320 RC 73010 HCPCS outpatient 298 223.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 268.2 90 999999999 232.44 283.1 percent of total billed charges "RADIOLOGIC EXAMINATION; SCAPULA, COMPLETE" 9512995_1 CDM 320 RC 73010 HCPCS outpatient 298 223.5 AETNA MCR ADV AETNA MCR ADV 232.44 78 999999999 232.44 283.1 percent of total billed charges "RADIOLOGIC EXAMINATION; SCAPULA, COMPLETE" 9512995_1 CDM 320 RC 73010 HCPCS outpatient 298 223.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 260.96 87.57 999999999 232.44 283.1 percent of total billed charges "RADIOLOGIC EXAMINATION; SCAPULA, COMPLETE" 9512995_1 CDM 320 RC 73010 HCPCS outpatient 298 223.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 253.51 85.07 999999999 232.44 283.1 percent of total billed charges "RADIOLOGIC EXAMINATION; SCAPULA, COMPLETE" 9512995_1 CDM 320 RC 73010 HCPCS outpatient 298 223.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 253.51 85.07 999999999 232.44 283.1 percent of total billed charges "RADIOLOGIC EXAMINATION; SCAPULA, COMPLETE" 9512995_1 CDM 320 RC 73010 HCPCS outpatient 298 223.5 MOLINA MCAID MOLINA MCAID 248.53 83.4 999999999 232.44 283.1 percent of total billed charges "RADIOLOGIC EXAMINATION; SCAPULA, COMPLETE" 9512995_1 CDM 320 RC 73010 HCPCS outpatient 298 223.5 MOLINA MCR ADV MOLINA MCR ADV 265.22 89 999999999 232.44 283.1 percent of total billed charges "RADIOLOGIC EXAMINATION; SCAPULA, COMPLETE" 9512995_1 CDM 320 RC 73010 HCPCS outpatient 298 223.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 265.22 89 999999999 232.44 283.1 percent of total billed charges "RADIOLOGIC EXAMINATION; SCAPULA, COMPLETE" 9512995_1 CDM 320 RC 73010 HCPCS outpatient 298 223.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 265.22 89 999999999 232.44 283.1 percent of total billed charges "RADIOLOGIC EXAMINATION; SCAPULA, COMPLETE" 9512995_1 CDM 320 RC 73010 HCPCS outpatient 298 223.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 268.2 90 999999999 232.44 283.1 percent of total billed charges "RADIOLOGIC EXAMINATION; SCAPULA, COMPLETE" 9512995_1 CDM 320 RC 73010 HCPCS outpatient 298 223.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 283.1 95 999999999 232.44 283.1 percent of total billed charges "RADIOLOGIC EXAMINATION; SCAPULA, COMPLETE" 9512995_1 CDM 320 RC 73010 HCPCS outpatient 298 223.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 283.1 95 999999999 232.44 283.1 percent of total billed charges "RADIOLOGIC EXAMINATION; SCAPULA, COMPLETE" 9512995_1 CDM 320 RC 73010 HCPCS outpatient 298 223.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 265.22 89 999999999 232.44 283.1 percent of total billed charges "RADIOLOGIC EXAMINATION; SCAPULA, COMPLETE" 9512995_1 CDM 320 RC 73010 HCPCS outpatient 298 223.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 262.24 88 999999999 232.44 283.1 percent of total billed charges "RADIOLOGIC EXAMINATION; SCAPULA, COMPLETE" 9512995_1 CDM 320 RC 73010 HCPCS outpatient 298 223.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 265.22 89 999999999 232.44 283.1 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; 1 VIEW" 9512998_1 CDM 320 RC 73020 HCPCS outpatient 239 179.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 215.1 90 999999999 186.42 227.05 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; 1 VIEW" 9512998_1 CDM 320 RC 73020 HCPCS outpatient 239 179.25 AETNA MCR ADV AETNA MCR ADV 186.42 78 999999999 186.42 227.05 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; 1 VIEW" 9512998_1 CDM 320 RC 73020 HCPCS outpatient 239 179.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 209.29 87.57 999999999 186.42 227.05 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; 1 VIEW" 9512998_1 CDM 320 RC 73020 HCPCS outpatient 239 179.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 203.32 85.07 999999999 186.42 227.05 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; 1 VIEW" 9512998_1 CDM 320 RC 73020 HCPCS outpatient 239 179.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 203.32 85.07 999999999 186.42 227.05 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; 1 VIEW" 9512998_1 CDM 320 RC 73020 HCPCS outpatient 239 179.25 MOLINA MCAID MOLINA MCAID 199.33 83.4 999999999 186.42 227.05 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; 1 VIEW" 9512998_1 CDM 320 RC 73020 HCPCS outpatient 239 179.25 MOLINA MCR ADV MOLINA MCR ADV 212.71 89 999999999 186.42 227.05 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; 1 VIEW" 9512998_1 CDM 320 RC 73020 HCPCS outpatient 239 179.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 212.71 89 999999999 186.42 227.05 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; 1 VIEW" 9512998_1 CDM 320 RC 73020 HCPCS outpatient 239 179.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 212.71 89 999999999 186.42 227.05 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; 1 VIEW" 9512998_1 CDM 320 RC 73020 HCPCS outpatient 239 179.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 215.1 90 999999999 186.42 227.05 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; 1 VIEW" 9512998_1 CDM 320 RC 73020 HCPCS outpatient 239 179.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 227.05 95 999999999 186.42 227.05 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; 1 VIEW" 9512998_1 CDM 320 RC 73020 HCPCS outpatient 239 179.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 227.05 95 999999999 186.42 227.05 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; 1 VIEW" 9512998_1 CDM 320 RC 73020 HCPCS outpatient 239 179.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 212.71 89 999999999 186.42 227.05 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; 1 VIEW" 9512998_1 CDM 320 RC 73020 HCPCS outpatient 239 179.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 210.32 88 999999999 186.42 227.05 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; 1 VIEW" 9512998_1 CDM 320 RC 73020 HCPCS outpatient 239 179.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 212.71 89 999999999 186.42 227.05 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE, MINIMUM OF 2 VIEWS" 9513001_1 CDM 320 RC 73030 HCPCS outpatient 329 246.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 296.1 90 999999999 256.62 312.55 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE, MINIMUM OF 2 VIEWS" 9513001_1 CDM 320 RC 73030 HCPCS outpatient 329 246.75 AETNA MCR ADV AETNA MCR ADV 256.62 78 999999999 256.62 312.55 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE, MINIMUM OF 2 VIEWS" 9513001_1 CDM 320 RC 73030 HCPCS outpatient 329 246.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 288.11 87.57 999999999 256.62 312.55 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE, MINIMUM OF 2 VIEWS" 9513001_1 CDM 320 RC 73030 HCPCS outpatient 329 246.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 279.88 85.07 999999999 256.62 312.55 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE, MINIMUM OF 2 VIEWS" 9513001_1 CDM 320 RC 73030 HCPCS outpatient 329 246.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 279.88 85.07 999999999 256.62 312.55 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE, MINIMUM OF 2 VIEWS" 9513001_1 CDM 320 RC 73030 HCPCS outpatient 329 246.75 MOLINA MCAID MOLINA MCAID 274.39 83.4 999999999 256.62 312.55 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE, MINIMUM OF 2 VIEWS" 9513001_1 CDM 320 RC 73030 HCPCS outpatient 329 246.75 MOLINA MCR ADV MOLINA MCR ADV 292.81 89 999999999 256.62 312.55 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE, MINIMUM OF 2 VIEWS" 9513001_1 CDM 320 RC 73030 HCPCS outpatient 329 246.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 292.81 89 999999999 256.62 312.55 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE, MINIMUM OF 2 VIEWS" 9513001_1 CDM 320 RC 73030 HCPCS outpatient 329 246.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 292.81 89 999999999 256.62 312.55 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE, MINIMUM OF 2 VIEWS" 9513001_1 CDM 320 RC 73030 HCPCS outpatient 329 246.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 296.1 90 999999999 256.62 312.55 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE, MINIMUM OF 2 VIEWS" 9513001_1 CDM 320 RC 73030 HCPCS outpatient 329 246.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 312.55 95 999999999 256.62 312.55 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE, MINIMUM OF 2 VIEWS" 9513001_1 CDM 320 RC 73030 HCPCS outpatient 329 246.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 312.55 95 999999999 256.62 312.55 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE, MINIMUM OF 2 VIEWS" 9513001_1 CDM 320 RC 73030 HCPCS outpatient 329 246.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 292.81 89 999999999 256.62 312.55 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE, MINIMUM OF 2 VIEWS" 9513001_1 CDM 320 RC 73030 HCPCS outpatient 329 246.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 289.52 88 999999999 256.62 312.55 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE, MINIMUM OF 2 VIEWS" 9513001_1 CDM 320 RC 73030 HCPCS outpatient 329 246.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 292.81 89 999999999 256.62 312.55 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE, MINIMUM OF 2 VIEWS" 9513001_50_1 CDM 320 RC 73030 HCPCS outpatient 494 370.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 444.6 90 999999999 385.32 469.3 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE, MINIMUM OF 2 VIEWS" 9513001_50_1 CDM 320 RC 73030 HCPCS outpatient 494 370.5 AETNA MCR ADV AETNA MCR ADV 50 385.32 78 999999999 385.32 469.3 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE, MINIMUM OF 2 VIEWS" 9513001_50_1 CDM 320 RC 73030 HCPCS outpatient 494 370.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 432.6 87.57 999999999 385.32 469.3 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE, MINIMUM OF 2 VIEWS" 9513001_50_1 CDM 320 RC 73030 HCPCS outpatient 494 370.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 420.25 85.07 999999999 385.32 469.3 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE, MINIMUM OF 2 VIEWS" 9513001_50_1 CDM 320 RC 73030 HCPCS outpatient 494 370.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 420.25 85.07 999999999 385.32 469.3 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE, MINIMUM OF 2 VIEWS" 9513001_50_1 CDM 320 RC 73030 HCPCS outpatient 494 370.5 MOLINA MCAID MOLINA MCAID 50 412 83.4 999999999 385.32 469.3 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE, MINIMUM OF 2 VIEWS" 9513001_50_1 CDM 320 RC 73030 HCPCS outpatient 494 370.5 MOLINA MCR ADV MOLINA MCR ADV 50 439.66 89 999999999 385.32 469.3 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE, MINIMUM OF 2 VIEWS" 9513001_50_1 CDM 320 RC 73030 HCPCS outpatient 494 370.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 439.66 89 999999999 385.32 469.3 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE, MINIMUM OF 2 VIEWS" 9513001_50_1 CDM 320 RC 73030 HCPCS outpatient 494 370.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 439.66 89 999999999 385.32 469.3 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE, MINIMUM OF 2 VIEWS" 9513001_50_1 CDM 320 RC 73030 HCPCS outpatient 494 370.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 444.6 90 999999999 385.32 469.3 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE, MINIMUM OF 2 VIEWS" 9513001_50_1 CDM 320 RC 73030 HCPCS outpatient 494 370.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 469.3 95 999999999 385.32 469.3 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE, MINIMUM OF 2 VIEWS" 9513001_50_1 CDM 320 RC 73030 HCPCS outpatient 494 370.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 469.3 95 999999999 385.32 469.3 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE, MINIMUM OF 2 VIEWS" 9513001_50_1 CDM 320 RC 73030 HCPCS outpatient 494 370.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 439.66 89 999999999 385.32 469.3 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE, MINIMUM OF 2 VIEWS" 9513001_50_1 CDM 320 RC 73030 HCPCS outpatient 494 370.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 434.72 88 999999999 385.32 469.3 percent of total billed charges "RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE, MINIMUM OF 2 VIEWS" 9513001_50_1 CDM 320 RC 73030 HCPCS outpatient 494 370.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 439.66 89 999999999 385.32 469.3 percent of total billed charges "RADIOLOGIC EXAMINATION; ACROMIOCLAVICULAR JOINTS, BILATERAL, WITH OR WITHOUT WEIGHTED DISTRACTION" 9513007_1 CDM 320 RC 73050 HCPCS outpatient 463 347.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 416.7 90 999999999 361.14 439.85 percent of total billed charges "RADIOLOGIC EXAMINATION; ACROMIOCLAVICULAR JOINTS, BILATERAL, WITH OR WITHOUT WEIGHTED DISTRACTION" 9513007_1 CDM 320 RC 73050 HCPCS outpatient 463 347.25 AETNA MCR ADV AETNA MCR ADV 361.14 78 999999999 361.14 439.85 percent of total billed charges "RADIOLOGIC EXAMINATION; ACROMIOCLAVICULAR JOINTS, BILATERAL, WITH OR WITHOUT WEIGHTED DISTRACTION" 9513007_1 CDM 320 RC 73050 HCPCS outpatient 463 347.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 405.45 87.57 999999999 361.14 439.85 percent of total billed charges "RADIOLOGIC EXAMINATION; ACROMIOCLAVICULAR JOINTS, BILATERAL, WITH OR WITHOUT WEIGHTED DISTRACTION" 9513007_1 CDM 320 RC 73050 HCPCS outpatient 463 347.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 393.87 85.07 999999999 361.14 439.85 percent of total billed charges "RADIOLOGIC EXAMINATION; ACROMIOCLAVICULAR JOINTS, BILATERAL, WITH OR WITHOUT WEIGHTED DISTRACTION" 9513007_1 CDM 320 RC 73050 HCPCS outpatient 463 347.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 393.87 85.07 999999999 361.14 439.85 percent of total billed charges "RADIOLOGIC EXAMINATION; ACROMIOCLAVICULAR JOINTS, BILATERAL, WITH OR WITHOUT WEIGHTED DISTRACTION" 9513007_1 CDM 320 RC 73050 HCPCS outpatient 463 347.25 MOLINA MCAID MOLINA MCAID 386.14 83.4 999999999 361.14 439.85 percent of total billed charges "RADIOLOGIC EXAMINATION; ACROMIOCLAVICULAR JOINTS, BILATERAL, WITH OR WITHOUT WEIGHTED DISTRACTION" 9513007_1 CDM 320 RC 73050 HCPCS outpatient 463 347.25 MOLINA MCR ADV MOLINA MCR ADV 412.07 89 999999999 361.14 439.85 percent of total billed charges "RADIOLOGIC EXAMINATION; ACROMIOCLAVICULAR JOINTS, BILATERAL, WITH OR WITHOUT WEIGHTED DISTRACTION" 9513007_1 CDM 320 RC 73050 HCPCS outpatient 463 347.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 412.07 89 999999999 361.14 439.85 percent of total billed charges "RADIOLOGIC EXAMINATION; ACROMIOCLAVICULAR JOINTS, BILATERAL, WITH OR WITHOUT WEIGHTED DISTRACTION" 9513007_1 CDM 320 RC 73050 HCPCS outpatient 463 347.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 412.07 89 999999999 361.14 439.85 percent of total billed charges "RADIOLOGIC EXAMINATION; ACROMIOCLAVICULAR JOINTS, BILATERAL, WITH OR WITHOUT WEIGHTED DISTRACTION" 9513007_1 CDM 320 RC 73050 HCPCS outpatient 463 347.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 416.7 90 999999999 361.14 439.85 percent of total billed charges "RADIOLOGIC EXAMINATION; ACROMIOCLAVICULAR JOINTS, BILATERAL, WITH OR WITHOUT WEIGHTED DISTRACTION" 9513007_1 CDM 320 RC 73050 HCPCS outpatient 463 347.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 439.85 95 999999999 361.14 439.85 percent of total billed charges "RADIOLOGIC EXAMINATION; ACROMIOCLAVICULAR JOINTS, BILATERAL, WITH OR WITHOUT WEIGHTED DISTRACTION" 9513007_1 CDM 320 RC 73050 HCPCS outpatient 463 347.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 439.85 95 999999999 361.14 439.85 percent of total billed charges "RADIOLOGIC EXAMINATION; ACROMIOCLAVICULAR JOINTS, BILATERAL, WITH OR WITHOUT WEIGHTED DISTRACTION" 9513007_1 CDM 320 RC 73050 HCPCS outpatient 463 347.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 412.07 89 999999999 361.14 439.85 percent of total billed charges "RADIOLOGIC EXAMINATION; ACROMIOCLAVICULAR JOINTS, BILATERAL, WITH OR WITHOUT WEIGHTED DISTRACTION" 9513007_1 CDM 320 RC 73050 HCPCS outpatient 463 347.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 407.44 88 999999999 361.14 439.85 percent of total billed charges "RADIOLOGIC EXAMINATION; ACROMIOCLAVICULAR JOINTS, BILATERAL, WITH OR WITHOUT WEIGHTED DISTRACTION" 9513007_1 CDM 320 RC 73050 HCPCS outpatient 463 347.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 412.07 89 999999999 361.14 439.85 percent of total billed charges "RADIOLOGIC EXAMINATION; HUMERUS, MINIMUM OF 2 VIEWS" 9513010_1 CDM 320 RC 73060 HCPCS outpatient 306 229.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 275.4 90 999999999 238.68 290.7 percent of total billed charges "RADIOLOGIC EXAMINATION; HUMERUS, MINIMUM OF 2 VIEWS" 9513010_1 CDM 320 RC 73060 HCPCS outpatient 306 229.5 AETNA MCR ADV AETNA MCR ADV 238.68 78 999999999 238.68 290.7 percent of total billed charges "RADIOLOGIC EXAMINATION; HUMERUS, MINIMUM OF 2 VIEWS" 9513010_1 CDM 320 RC 73060 HCPCS outpatient 306 229.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 267.96 87.57 999999999 238.68 290.7 percent of total billed charges "RADIOLOGIC EXAMINATION; HUMERUS, MINIMUM OF 2 VIEWS" 9513010_1 CDM 320 RC 73060 HCPCS outpatient 306 229.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 260.31 85.07 999999999 238.68 290.7 percent of total billed charges "RADIOLOGIC EXAMINATION; HUMERUS, MINIMUM OF 2 VIEWS" 9513010_1 CDM 320 RC 73060 HCPCS outpatient 306 229.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 260.31 85.07 999999999 238.68 290.7 percent of total billed charges "RADIOLOGIC EXAMINATION; HUMERUS, MINIMUM OF 2 VIEWS" 9513010_1 CDM 320 RC 73060 HCPCS outpatient 306 229.5 MOLINA MCAID MOLINA MCAID 255.2 83.4 999999999 238.68 290.7 percent of total billed charges "RADIOLOGIC EXAMINATION; HUMERUS, MINIMUM OF 2 VIEWS" 9513010_1 CDM 320 RC 73060 HCPCS outpatient 306 229.5 MOLINA MCR ADV MOLINA MCR ADV 272.34 89 999999999 238.68 290.7 percent of total billed charges "RADIOLOGIC EXAMINATION; HUMERUS, MINIMUM OF 2 VIEWS" 9513010_1 CDM 320 RC 73060 HCPCS outpatient 306 229.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 272.34 89 999999999 238.68 290.7 percent of total billed charges "RADIOLOGIC EXAMINATION; HUMERUS, MINIMUM OF 2 VIEWS" 9513010_1 CDM 320 RC 73060 HCPCS outpatient 306 229.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 272.34 89 999999999 238.68 290.7 percent of total billed charges "RADIOLOGIC EXAMINATION; HUMERUS, MINIMUM OF 2 VIEWS" 9513010_1 CDM 320 RC 73060 HCPCS outpatient 306 229.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 275.4 90 999999999 238.68 290.7 percent of total billed charges "RADIOLOGIC EXAMINATION; HUMERUS, MINIMUM OF 2 VIEWS" 9513010_1 CDM 320 RC 73060 HCPCS outpatient 306 229.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 290.7 95 999999999 238.68 290.7 percent of total billed charges "RADIOLOGIC EXAMINATION; HUMERUS, MINIMUM OF 2 VIEWS" 9513010_1 CDM 320 RC 73060 HCPCS outpatient 306 229.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 290.7 95 999999999 238.68 290.7 percent of total billed charges "RADIOLOGIC EXAMINATION; HUMERUS, MINIMUM OF 2 VIEWS" 9513010_1 CDM 320 RC 73060 HCPCS outpatient 306 229.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 272.34 89 999999999 238.68 290.7 percent of total billed charges "RADIOLOGIC EXAMINATION; HUMERUS, MINIMUM OF 2 VIEWS" 9513010_1 CDM 320 RC 73060 HCPCS outpatient 306 229.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 269.28 88 999999999 238.68 290.7 percent of total billed charges "RADIOLOGIC EXAMINATION; HUMERUS, MINIMUM OF 2 VIEWS" 9513010_1 CDM 320 RC 73060 HCPCS outpatient 306 229.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 272.34 89 999999999 238.68 290.7 percent of total billed charges "RADIOLOGIC EXAMINATION, ELBOW; COMPLETE, MINIMUM OF 3 VIEWS" 9513016_1 CDM 320 RC 73080 HCPCS outpatient 318 238.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 286.2 90 999999999 248.04 302.1 percent of total billed charges "RADIOLOGIC EXAMINATION, ELBOW; COMPLETE, MINIMUM OF 3 VIEWS" 9513016_1 CDM 320 RC 73080 HCPCS outpatient 318 238.5 AETNA MCR ADV AETNA MCR ADV 248.04 78 999999999 248.04 302.1 percent of total billed charges "RADIOLOGIC EXAMINATION, ELBOW; COMPLETE, MINIMUM OF 3 VIEWS" 9513016_1 CDM 320 RC 73080 HCPCS outpatient 318 238.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 278.47 87.57 999999999 248.04 302.1 percent of total billed charges "RADIOLOGIC EXAMINATION, ELBOW; COMPLETE, MINIMUM OF 3 VIEWS" 9513016_1 CDM 320 RC 73080 HCPCS outpatient 318 238.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 270.52 85.07 999999999 248.04 302.1 percent of total billed charges "RADIOLOGIC EXAMINATION, ELBOW; COMPLETE, MINIMUM OF 3 VIEWS" 9513016_1 CDM 320 RC 73080 HCPCS outpatient 318 238.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 270.52 85.07 999999999 248.04 302.1 percent of total billed charges "RADIOLOGIC EXAMINATION, ELBOW; COMPLETE, MINIMUM OF 3 VIEWS" 9513016_1 CDM 320 RC 73080 HCPCS outpatient 318 238.5 MOLINA MCAID MOLINA MCAID 265.21 83.4 999999999 248.04 302.1 percent of total billed charges "RADIOLOGIC EXAMINATION, ELBOW; COMPLETE, MINIMUM OF 3 VIEWS" 9513016_1 CDM 320 RC 73080 HCPCS outpatient 318 238.5 MOLINA MCR ADV MOLINA MCR ADV 283.02 89 999999999 248.04 302.1 percent of total billed charges "RADIOLOGIC EXAMINATION, ELBOW; COMPLETE, MINIMUM OF 3 VIEWS" 9513016_1 CDM 320 RC 73080 HCPCS outpatient 318 238.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 283.02 89 999999999 248.04 302.1 percent of total billed charges "RADIOLOGIC EXAMINATION, ELBOW; COMPLETE, MINIMUM OF 3 VIEWS" 9513016_1 CDM 320 RC 73080 HCPCS outpatient 318 238.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 283.02 89 999999999 248.04 302.1 percent of total billed charges "RADIOLOGIC EXAMINATION, ELBOW; COMPLETE, MINIMUM OF 3 VIEWS" 9513016_1 CDM 320 RC 73080 HCPCS outpatient 318 238.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 286.2 90 999999999 248.04 302.1 percent of total billed charges "RADIOLOGIC EXAMINATION, ELBOW; COMPLETE, MINIMUM OF 3 VIEWS" 9513016_1 CDM 320 RC 73080 HCPCS outpatient 318 238.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 302.1 95 999999999 248.04 302.1 percent of total billed charges "RADIOLOGIC EXAMINATION, ELBOW; COMPLETE, MINIMUM OF 3 VIEWS" 9513016_1 CDM 320 RC 73080 HCPCS outpatient 318 238.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 302.1 95 999999999 248.04 302.1 percent of total billed charges "RADIOLOGIC EXAMINATION, ELBOW; COMPLETE, MINIMUM OF 3 VIEWS" 9513016_1 CDM 320 RC 73080 HCPCS outpatient 318 238.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 283.02 89 999999999 248.04 302.1 percent of total billed charges "RADIOLOGIC EXAMINATION, ELBOW; COMPLETE, MINIMUM OF 3 VIEWS" 9513016_1 CDM 320 RC 73080 HCPCS outpatient 318 238.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 279.84 88 999999999 248.04 302.1 percent of total billed charges "RADIOLOGIC EXAMINATION, ELBOW; COMPLETE, MINIMUM OF 3 VIEWS" 9513016_1 CDM 320 RC 73080 HCPCS outpatient 318 238.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 283.02 89 999999999 248.04 302.1 percent of total billed charges "RADIOLOGIC EXAMINATION; FOREARM, 2 VIEWS" 9513022_1 CDM 320 RC 73090 HCPCS outpatient 329 246.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 296.1 90 999999999 256.62 312.55 percent of total billed charges "RADIOLOGIC EXAMINATION; FOREARM, 2 VIEWS" 9513022_1 CDM 320 RC 73090 HCPCS outpatient 329 246.75 AETNA MCR ADV AETNA MCR ADV 256.62 78 999999999 256.62 312.55 percent of total billed charges "RADIOLOGIC EXAMINATION; FOREARM, 2 VIEWS" 9513022_1 CDM 320 RC 73090 HCPCS outpatient 329 246.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 288.11 87.57 999999999 256.62 312.55 percent of total billed charges "RADIOLOGIC EXAMINATION; FOREARM, 2 VIEWS" 9513022_1 CDM 320 RC 73090 HCPCS outpatient 329 246.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 279.88 85.07 999999999 256.62 312.55 percent of total billed charges "RADIOLOGIC EXAMINATION; FOREARM, 2 VIEWS" 9513022_1 CDM 320 RC 73090 HCPCS outpatient 329 246.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 279.88 85.07 999999999 256.62 312.55 percent of total billed charges "RADIOLOGIC EXAMINATION; FOREARM, 2 VIEWS" 9513022_1 CDM 320 RC 73090 HCPCS outpatient 329 246.75 MOLINA MCAID MOLINA MCAID 274.39 83.4 999999999 256.62 312.55 percent of total billed charges "RADIOLOGIC EXAMINATION; FOREARM, 2 VIEWS" 9513022_1 CDM 320 RC 73090 HCPCS outpatient 329 246.75 MOLINA MCR ADV MOLINA MCR ADV 292.81 89 999999999 256.62 312.55 percent of total billed charges "RADIOLOGIC EXAMINATION; FOREARM, 2 VIEWS" 9513022_1 CDM 320 RC 73090 HCPCS outpatient 329 246.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 292.81 89 999999999 256.62 312.55 percent of total billed charges "RADIOLOGIC EXAMINATION; FOREARM, 2 VIEWS" 9513022_1 CDM 320 RC 73090 HCPCS outpatient 329 246.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 292.81 89 999999999 256.62 312.55 percent of total billed charges "RADIOLOGIC EXAMINATION; FOREARM, 2 VIEWS" 9513022_1 CDM 320 RC 73090 HCPCS outpatient 329 246.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 296.1 90 999999999 256.62 312.55 percent of total billed charges "RADIOLOGIC EXAMINATION; FOREARM, 2 VIEWS" 9513022_1 CDM 320 RC 73090 HCPCS outpatient 329 246.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 312.55 95 999999999 256.62 312.55 percent of total billed charges "RADIOLOGIC EXAMINATION; FOREARM, 2 VIEWS" 9513022_1 CDM 320 RC 73090 HCPCS outpatient 329 246.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 312.55 95 999999999 256.62 312.55 percent of total billed charges "RADIOLOGIC EXAMINATION; FOREARM, 2 VIEWS" 9513022_1 CDM 320 RC 73090 HCPCS outpatient 329 246.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 292.81 89 999999999 256.62 312.55 percent of total billed charges "RADIOLOGIC EXAMINATION; FOREARM, 2 VIEWS" 9513022_1 CDM 320 RC 73090 HCPCS outpatient 329 246.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 289.52 88 999999999 256.62 312.55 percent of total billed charges "RADIOLOGIC EXAMINATION; FOREARM, 2 VIEWS" 9513022_1 CDM 320 RC 73090 HCPCS outpatient 329 246.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 292.81 89 999999999 256.62 312.55 percent of total billed charges "RADIOLOGIC EXAMINATION; FOREARM, 2 VIEWS" 9513022_50_1 CDM 320 RC 73090 HCPCS outpatient 494 370.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 444.6 90 999999999 385.32 469.3 percent of total billed charges "RADIOLOGIC EXAMINATION; FOREARM, 2 VIEWS" 9513022_50_1 CDM 320 RC 73090 HCPCS outpatient 494 370.5 AETNA MCR ADV AETNA MCR ADV 50 385.32 78 999999999 385.32 469.3 percent of total billed charges "RADIOLOGIC EXAMINATION; FOREARM, 2 VIEWS" 9513022_50_1 CDM 320 RC 73090 HCPCS outpatient 494 370.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 432.6 87.57 999999999 385.32 469.3 percent of total billed charges "RADIOLOGIC EXAMINATION; FOREARM, 2 VIEWS" 9513022_50_1 CDM 320 RC 73090 HCPCS outpatient 494 370.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 420.25 85.07 999999999 385.32 469.3 percent of total billed charges "RADIOLOGIC EXAMINATION; FOREARM, 2 VIEWS" 9513022_50_1 CDM 320 RC 73090 HCPCS outpatient 494 370.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 420.25 85.07 999999999 385.32 469.3 percent of total billed charges "RADIOLOGIC EXAMINATION; FOREARM, 2 VIEWS" 9513022_50_1 CDM 320 RC 73090 HCPCS outpatient 494 370.5 MOLINA MCAID MOLINA MCAID 50 412 83.4 999999999 385.32 469.3 percent of total billed charges "RADIOLOGIC EXAMINATION; FOREARM, 2 VIEWS" 9513022_50_1 CDM 320 RC 73090 HCPCS outpatient 494 370.5 MOLINA MCR ADV MOLINA MCR ADV 50 439.66 89 999999999 385.32 469.3 percent of total billed charges "RADIOLOGIC EXAMINATION; FOREARM, 2 VIEWS" 9513022_50_1 CDM 320 RC 73090 HCPCS outpatient 494 370.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 439.66 89 999999999 385.32 469.3 percent of total billed charges "RADIOLOGIC EXAMINATION; FOREARM, 2 VIEWS" 9513022_50_1 CDM 320 RC 73090 HCPCS outpatient 494 370.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 439.66 89 999999999 385.32 469.3 percent of total billed charges "RADIOLOGIC EXAMINATION; FOREARM, 2 VIEWS" 9513022_50_1 CDM 320 RC 73090 HCPCS outpatient 494 370.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 444.6 90 999999999 385.32 469.3 percent of total billed charges "RADIOLOGIC EXAMINATION; FOREARM, 2 VIEWS" 9513022_50_1 CDM 320 RC 73090 HCPCS outpatient 494 370.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 469.3 95 999999999 385.32 469.3 percent of total billed charges "RADIOLOGIC EXAMINATION; FOREARM, 2 VIEWS" 9513022_50_1 CDM 320 RC 73090 HCPCS outpatient 494 370.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 469.3 95 999999999 385.32 469.3 percent of total billed charges "RADIOLOGIC EXAMINATION; FOREARM, 2 VIEWS" 9513022_50_1 CDM 320 RC 73090 HCPCS outpatient 494 370.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 439.66 89 999999999 385.32 469.3 percent of total billed charges "RADIOLOGIC EXAMINATION; FOREARM, 2 VIEWS" 9513022_50_1 CDM 320 RC 73090 HCPCS outpatient 494 370.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 434.72 88 999999999 385.32 469.3 percent of total billed charges "RADIOLOGIC EXAMINATION; FOREARM, 2 VIEWS" 9513022_50_1 CDM 320 RC 73090 HCPCS outpatient 494 370.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 439.66 89 999999999 385.32 469.3 percent of total billed charges "RADIOLOGIC EXAMINATION; UPPER EXTREMITY, INFANT, MINIMUM OF 2 VIEWS" 9513025_1 CDM 320 RC 73092 HCPCS outpatient 334 250.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 300.6 90 999999999 260.52 317.3 percent of total billed charges "RADIOLOGIC EXAMINATION; UPPER EXTREMITY, INFANT, MINIMUM OF 2 VIEWS" 9513025_1 CDM 320 RC 73092 HCPCS outpatient 334 250.5 AETNA MCR ADV AETNA MCR ADV 260.52 78 999999999 260.52 317.3 percent of total billed charges "RADIOLOGIC EXAMINATION; UPPER EXTREMITY, INFANT, MINIMUM OF 2 VIEWS" 9513025_1 CDM 320 RC 73092 HCPCS outpatient 334 250.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 292.48 87.57 999999999 260.52 317.3 percent of total billed charges "RADIOLOGIC EXAMINATION; UPPER EXTREMITY, INFANT, MINIMUM OF 2 VIEWS" 9513025_1 CDM 320 RC 73092 HCPCS outpatient 334 250.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 284.13 85.07 999999999 260.52 317.3 percent of total billed charges "RADIOLOGIC EXAMINATION; UPPER EXTREMITY, INFANT, MINIMUM OF 2 VIEWS" 9513025_1 CDM 320 RC 73092 HCPCS outpatient 334 250.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 284.13 85.07 999999999 260.52 317.3 percent of total billed charges "RADIOLOGIC EXAMINATION; UPPER EXTREMITY, INFANT, MINIMUM OF 2 VIEWS" 9513025_1 CDM 320 RC 73092 HCPCS outpatient 334 250.5 MOLINA MCAID MOLINA MCAID 278.56 83.4 999999999 260.52 317.3 percent of total billed charges "RADIOLOGIC EXAMINATION; UPPER EXTREMITY, INFANT, MINIMUM OF 2 VIEWS" 9513025_1 CDM 320 RC 73092 HCPCS outpatient 334 250.5 MOLINA MCR ADV MOLINA MCR ADV 297.26 89 999999999 260.52 317.3 percent of total billed charges "RADIOLOGIC EXAMINATION; UPPER EXTREMITY, INFANT, MINIMUM OF 2 VIEWS" 9513025_1 CDM 320 RC 73092 HCPCS outpatient 334 250.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 297.26 89 999999999 260.52 317.3 percent of total billed charges "RADIOLOGIC EXAMINATION; UPPER EXTREMITY, INFANT, MINIMUM OF 2 VIEWS" 9513025_1 CDM 320 RC 73092 HCPCS outpatient 334 250.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 297.26 89 999999999 260.52 317.3 percent of total billed charges "RADIOLOGIC EXAMINATION; UPPER EXTREMITY, INFANT, MINIMUM OF 2 VIEWS" 9513025_1 CDM 320 RC 73092 HCPCS outpatient 334 250.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 300.6 90 999999999 260.52 317.3 percent of total billed charges "RADIOLOGIC EXAMINATION; UPPER EXTREMITY, INFANT, MINIMUM OF 2 VIEWS" 9513025_1 CDM 320 RC 73092 HCPCS outpatient 334 250.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 317.3 95 999999999 260.52 317.3 percent of total billed charges "RADIOLOGIC EXAMINATION; UPPER EXTREMITY, INFANT, MINIMUM OF 2 VIEWS" 9513025_1 CDM 320 RC 73092 HCPCS outpatient 334 250.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 317.3 95 999999999 260.52 317.3 percent of total billed charges "RADIOLOGIC EXAMINATION; UPPER EXTREMITY, INFANT, MINIMUM OF 2 VIEWS" 9513025_1 CDM 320 RC 73092 HCPCS outpatient 334 250.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 297.26 89 999999999 260.52 317.3 percent of total billed charges "RADIOLOGIC EXAMINATION; UPPER EXTREMITY, INFANT, MINIMUM OF 2 VIEWS" 9513025_1 CDM 320 RC 73092 HCPCS outpatient 334 250.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 293.92 88 999999999 260.52 317.3 percent of total billed charges "RADIOLOGIC EXAMINATION; UPPER EXTREMITY, INFANT, MINIMUM OF 2 VIEWS" 9513025_1 CDM 320 RC 73092 HCPCS outpatient 334 250.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 297.26 89 999999999 260.52 317.3 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; 2 VIEWS" 9513028_1 CDM 320 RC 73100 HCPCS outpatient 283 212.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 254.7 90 999999999 220.74 268.85 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; 2 VIEWS" 9513028_1 CDM 320 RC 73100 HCPCS outpatient 283 212.25 AETNA MCR ADV AETNA MCR ADV 220.74 78 999999999 220.74 268.85 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; 2 VIEWS" 9513028_1 CDM 320 RC 73100 HCPCS outpatient 283 212.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 247.82 87.57 999999999 220.74 268.85 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; 2 VIEWS" 9513028_1 CDM 320 RC 73100 HCPCS outpatient 283 212.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 240.75 85.07 999999999 220.74 268.85 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; 2 VIEWS" 9513028_1 CDM 320 RC 73100 HCPCS outpatient 283 212.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 240.75 85.07 999999999 220.74 268.85 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; 2 VIEWS" 9513028_1 CDM 320 RC 73100 HCPCS outpatient 283 212.25 MOLINA MCAID MOLINA MCAID 236.02 83.4 999999999 220.74 268.85 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; 2 VIEWS" 9513028_1 CDM 320 RC 73100 HCPCS outpatient 283 212.25 MOLINA MCR ADV MOLINA MCR ADV 251.87 89 999999999 220.74 268.85 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; 2 VIEWS" 9513028_1 CDM 320 RC 73100 HCPCS outpatient 283 212.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 251.87 89 999999999 220.74 268.85 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; 2 VIEWS" 9513028_1 CDM 320 RC 73100 HCPCS outpatient 283 212.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 251.87 89 999999999 220.74 268.85 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; 2 VIEWS" 9513028_1 CDM 320 RC 73100 HCPCS outpatient 283 212.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 254.7 90 999999999 220.74 268.85 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; 2 VIEWS" 9513028_1 CDM 320 RC 73100 HCPCS outpatient 283 212.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 268.85 95 999999999 220.74 268.85 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; 2 VIEWS" 9513028_1 CDM 320 RC 73100 HCPCS outpatient 283 212.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 268.85 95 999999999 220.74 268.85 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; 2 VIEWS" 9513028_1 CDM 320 RC 73100 HCPCS outpatient 283 212.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 251.87 89 999999999 220.74 268.85 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; 2 VIEWS" 9513028_1 CDM 320 RC 73100 HCPCS outpatient 283 212.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 249.04 88 999999999 220.74 268.85 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; 2 VIEWS" 9513028_1 CDM 320 RC 73100 HCPCS outpatient 283 212.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 251.87 89 999999999 220.74 268.85 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; COMPLETE, MINIMUM OF 3 VIEWS" 9513031_1 CDM 320 RC 73110 HCPCS outpatient 333 249.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 299.7 90 999999999 259.74 316.35 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; COMPLETE, MINIMUM OF 3 VIEWS" 9513031_1 CDM 320 RC 73110 HCPCS outpatient 333 249.75 AETNA MCR ADV AETNA MCR ADV 259.74 78 999999999 259.74 316.35 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; COMPLETE, MINIMUM OF 3 VIEWS" 9513031_1 CDM 320 RC 73110 HCPCS outpatient 333 249.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 291.61 87.57 999999999 259.74 316.35 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; COMPLETE, MINIMUM OF 3 VIEWS" 9513031_1 CDM 320 RC 73110 HCPCS outpatient 333 249.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 283.28 85.07 999999999 259.74 316.35 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; COMPLETE, MINIMUM OF 3 VIEWS" 9513031_1 CDM 320 RC 73110 HCPCS outpatient 333 249.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 283.28 85.07 999999999 259.74 316.35 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; COMPLETE, MINIMUM OF 3 VIEWS" 9513031_1 CDM 320 RC 73110 HCPCS outpatient 333 249.75 MOLINA MCAID MOLINA MCAID 277.72 83.4 999999999 259.74 316.35 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; COMPLETE, MINIMUM OF 3 VIEWS" 9513031_1 CDM 320 RC 73110 HCPCS outpatient 333 249.75 MOLINA MCR ADV MOLINA MCR ADV 296.37 89 999999999 259.74 316.35 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; COMPLETE, MINIMUM OF 3 VIEWS" 9513031_1 CDM 320 RC 73110 HCPCS outpatient 333 249.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 296.37 89 999999999 259.74 316.35 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; COMPLETE, MINIMUM OF 3 VIEWS" 9513031_1 CDM 320 RC 73110 HCPCS outpatient 333 249.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 296.37 89 999999999 259.74 316.35 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; COMPLETE, MINIMUM OF 3 VIEWS" 9513031_1 CDM 320 RC 73110 HCPCS outpatient 333 249.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 299.7 90 999999999 259.74 316.35 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; COMPLETE, MINIMUM OF 3 VIEWS" 9513031_1 CDM 320 RC 73110 HCPCS outpatient 333 249.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 316.35 95 999999999 259.74 316.35 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; COMPLETE, MINIMUM OF 3 VIEWS" 9513031_1 CDM 320 RC 73110 HCPCS outpatient 333 249.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 316.35 95 999999999 259.74 316.35 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; COMPLETE, MINIMUM OF 3 VIEWS" 9513031_1 CDM 320 RC 73110 HCPCS outpatient 333 249.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 296.37 89 999999999 259.74 316.35 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; COMPLETE, MINIMUM OF 3 VIEWS" 9513031_1 CDM 320 RC 73110 HCPCS outpatient 333 249.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 293.04 88 999999999 259.74 316.35 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; COMPLETE, MINIMUM OF 3 VIEWS" 9513031_1 CDM 320 RC 73110 HCPCS outpatient 333 249.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 296.37 89 999999999 259.74 316.35 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; COMPLETE, MINIMUM OF 3 VIEWS" 9513031_50_1 CDM 320 RC 73110 HCPCS outpatient 446 334.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 401.4 90 999999999 347.88 423.7 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; COMPLETE, MINIMUM OF 3 VIEWS" 9513031_50_1 CDM 320 RC 73110 HCPCS outpatient 446 334.5 AETNA MCR ADV AETNA MCR ADV 50 347.88 78 999999999 347.88 423.7 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; COMPLETE, MINIMUM OF 3 VIEWS" 9513031_50_1 CDM 320 RC 73110 HCPCS outpatient 446 334.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 390.56 87.57 999999999 347.88 423.7 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; COMPLETE, MINIMUM OF 3 VIEWS" 9513031_50_1 CDM 320 RC 73110 HCPCS outpatient 446 334.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 379.41 85.07 999999999 347.88 423.7 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; COMPLETE, MINIMUM OF 3 VIEWS" 9513031_50_1 CDM 320 RC 73110 HCPCS outpatient 446 334.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 379.41 85.07 999999999 347.88 423.7 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; COMPLETE, MINIMUM OF 3 VIEWS" 9513031_50_1 CDM 320 RC 73110 HCPCS outpatient 446 334.5 MOLINA MCAID MOLINA MCAID 50 371.96 83.4 999999999 347.88 423.7 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; COMPLETE, MINIMUM OF 3 VIEWS" 9513031_50_1 CDM 320 RC 73110 HCPCS outpatient 446 334.5 MOLINA MCR ADV MOLINA MCR ADV 50 396.94 89 999999999 347.88 423.7 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; COMPLETE, MINIMUM OF 3 VIEWS" 9513031_50_1 CDM 320 RC 73110 HCPCS outpatient 446 334.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 396.94 89 999999999 347.88 423.7 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; COMPLETE, MINIMUM OF 3 VIEWS" 9513031_50_1 CDM 320 RC 73110 HCPCS outpatient 446 334.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 396.94 89 999999999 347.88 423.7 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; COMPLETE, MINIMUM OF 3 VIEWS" 9513031_50_1 CDM 320 RC 73110 HCPCS outpatient 446 334.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 401.4 90 999999999 347.88 423.7 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; COMPLETE, MINIMUM OF 3 VIEWS" 9513031_50_1 CDM 320 RC 73110 HCPCS outpatient 446 334.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 423.7 95 999999999 347.88 423.7 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; COMPLETE, MINIMUM OF 3 VIEWS" 9513031_50_1 CDM 320 RC 73110 HCPCS outpatient 446 334.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 423.7 95 999999999 347.88 423.7 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; COMPLETE, MINIMUM OF 3 VIEWS" 9513031_50_1 CDM 320 RC 73110 HCPCS outpatient 446 334.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 396.94 89 999999999 347.88 423.7 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; COMPLETE, MINIMUM OF 3 VIEWS" 9513031_50_1 CDM 320 RC 73110 HCPCS outpatient 446 334.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 392.48 88 999999999 347.88 423.7 percent of total billed charges "RADIOLOGIC EXAMINATION, WRIST; COMPLETE, MINIMUM OF 3 VIEWS" 9513031_50_1 CDM 320 RC 73110 HCPCS outpatient 446 334.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 396.94 89 999999999 347.88 423.7 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; 2 VIEWS" 9513037_1 CDM 320 RC 73120 HCPCS outpatient 314 235.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 282.6 90 999999999 244.92 298.3 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; 2 VIEWS" 9513037_1 CDM 320 RC 73120 HCPCS outpatient 314 235.5 AETNA MCR ADV AETNA MCR ADV 244.92 78 999999999 244.92 298.3 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; 2 VIEWS" 9513037_1 CDM 320 RC 73120 HCPCS outpatient 314 235.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 274.97 87.57 999999999 244.92 298.3 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; 2 VIEWS" 9513037_1 CDM 320 RC 73120 HCPCS outpatient 314 235.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 267.12 85.07 999999999 244.92 298.3 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; 2 VIEWS" 9513037_1 CDM 320 RC 73120 HCPCS outpatient 314 235.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 267.12 85.07 999999999 244.92 298.3 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; 2 VIEWS" 9513037_1 CDM 320 RC 73120 HCPCS outpatient 314 235.5 MOLINA MCAID MOLINA MCAID 261.88 83.4 999999999 244.92 298.3 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; 2 VIEWS" 9513037_1 CDM 320 RC 73120 HCPCS outpatient 314 235.5 MOLINA MCR ADV MOLINA MCR ADV 279.46 89 999999999 244.92 298.3 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; 2 VIEWS" 9513037_1 CDM 320 RC 73120 HCPCS outpatient 314 235.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 279.46 89 999999999 244.92 298.3 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; 2 VIEWS" 9513037_1 CDM 320 RC 73120 HCPCS outpatient 314 235.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 279.46 89 999999999 244.92 298.3 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; 2 VIEWS" 9513037_1 CDM 320 RC 73120 HCPCS outpatient 314 235.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 282.6 90 999999999 244.92 298.3 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; 2 VIEWS" 9513037_1 CDM 320 RC 73120 HCPCS outpatient 314 235.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 298.3 95 999999999 244.92 298.3 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; 2 VIEWS" 9513037_1 CDM 320 RC 73120 HCPCS outpatient 314 235.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 298.3 95 999999999 244.92 298.3 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; 2 VIEWS" 9513037_1 CDM 320 RC 73120 HCPCS outpatient 314 235.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 279.46 89 999999999 244.92 298.3 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; 2 VIEWS" 9513037_1 CDM 320 RC 73120 HCPCS outpatient 314 235.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 276.32 88 999999999 244.92 298.3 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; 2 VIEWS" 9513037_1 CDM 320 RC 73120 HCPCS outpatient 314 235.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 279.46 89 999999999 244.92 298.3 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; MINIMUM OF 3 VIEWS" 9513040_1 CDM 320 RC 73130 HCPCS outpatient 357 267.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 321.3 90 999999999 278.46 339.15 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; MINIMUM OF 3 VIEWS" 9513040_1 CDM 320 RC 73130 HCPCS outpatient 357 267.75 AETNA MCR ADV AETNA MCR ADV 278.46 78 999999999 278.46 339.15 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; MINIMUM OF 3 VIEWS" 9513040_1 CDM 320 RC 73130 HCPCS outpatient 357 267.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 312.62 87.57 999999999 278.46 339.15 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; MINIMUM OF 3 VIEWS" 9513040_1 CDM 320 RC 73130 HCPCS outpatient 357 267.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 303.7 85.07 999999999 278.46 339.15 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; MINIMUM OF 3 VIEWS" 9513040_1 CDM 320 RC 73130 HCPCS outpatient 357 267.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 303.7 85.07 999999999 278.46 339.15 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; MINIMUM OF 3 VIEWS" 9513040_1 CDM 320 RC 73130 HCPCS outpatient 357 267.75 MOLINA MCAID MOLINA MCAID 297.74 83.4 999999999 278.46 339.15 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; MINIMUM OF 3 VIEWS" 9513040_1 CDM 320 RC 73130 HCPCS outpatient 357 267.75 MOLINA MCR ADV MOLINA MCR ADV 317.73 89 999999999 278.46 339.15 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; MINIMUM OF 3 VIEWS" 9513040_1 CDM 320 RC 73130 HCPCS outpatient 357 267.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 317.73 89 999999999 278.46 339.15 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; MINIMUM OF 3 VIEWS" 9513040_1 CDM 320 RC 73130 HCPCS outpatient 357 267.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 317.73 89 999999999 278.46 339.15 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; MINIMUM OF 3 VIEWS" 9513040_1 CDM 320 RC 73130 HCPCS outpatient 357 267.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 321.3 90 999999999 278.46 339.15 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; MINIMUM OF 3 VIEWS" 9513040_1 CDM 320 RC 73130 HCPCS outpatient 357 267.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 339.15 95 999999999 278.46 339.15 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; MINIMUM OF 3 VIEWS" 9513040_1 CDM 320 RC 73130 HCPCS outpatient 357 267.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 339.15 95 999999999 278.46 339.15 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; MINIMUM OF 3 VIEWS" 9513040_1 CDM 320 RC 73130 HCPCS outpatient 357 267.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 317.73 89 999999999 278.46 339.15 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; MINIMUM OF 3 VIEWS" 9513040_1 CDM 320 RC 73130 HCPCS outpatient 357 267.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 314.16 88 999999999 278.46 339.15 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; MINIMUM OF 3 VIEWS" 9513040_1 CDM 320 RC 73130 HCPCS outpatient 357 267.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 317.73 89 999999999 278.46 339.15 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; MINIMUM OF 3 VIEWS" 9513040_50_1 CDM 320 RC 73130 HCPCS outpatient 536 402 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 482.4 90 999999999 418.08 509.2 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; MINIMUM OF 3 VIEWS" 9513040_50_1 CDM 320 RC 73130 HCPCS outpatient 536 402 AETNA MCR ADV AETNA MCR ADV 50 418.08 78 999999999 418.08 509.2 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; MINIMUM OF 3 VIEWS" 9513040_50_1 CDM 320 RC 73130 HCPCS outpatient 536 402 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 469.38 87.57 999999999 418.08 509.2 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; MINIMUM OF 3 VIEWS" 9513040_50_1 CDM 320 RC 73130 HCPCS outpatient 536 402 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 455.98 85.07 999999999 418.08 509.2 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; MINIMUM OF 3 VIEWS" 9513040_50_1 CDM 320 RC 73130 HCPCS outpatient 536 402 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 455.98 85.07 999999999 418.08 509.2 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; MINIMUM OF 3 VIEWS" 9513040_50_1 CDM 320 RC 73130 HCPCS outpatient 536 402 MOLINA MCAID MOLINA MCAID 50 447.02 83.4 999999999 418.08 509.2 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; MINIMUM OF 3 VIEWS" 9513040_50_1 CDM 320 RC 73130 HCPCS outpatient 536 402 MOLINA MCR ADV MOLINA MCR ADV 50 477.04 89 999999999 418.08 509.2 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; MINIMUM OF 3 VIEWS" 9513040_50_1 CDM 320 RC 73130 HCPCS outpatient 536 402 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 477.04 89 999999999 418.08 509.2 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; MINIMUM OF 3 VIEWS" 9513040_50_1 CDM 320 RC 73130 HCPCS outpatient 536 402 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 477.04 89 999999999 418.08 509.2 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; MINIMUM OF 3 VIEWS" 9513040_50_1 CDM 320 RC 73130 HCPCS outpatient 536 402 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 482.4 90 999999999 418.08 509.2 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; MINIMUM OF 3 VIEWS" 9513040_50_1 CDM 320 RC 73130 HCPCS outpatient 536 402 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 509.2 95 999999999 418.08 509.2 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; MINIMUM OF 3 VIEWS" 9513040_50_1 CDM 320 RC 73130 HCPCS outpatient 536 402 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 509.2 95 999999999 418.08 509.2 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; MINIMUM OF 3 VIEWS" 9513040_50_1 CDM 320 RC 73130 HCPCS outpatient 536 402 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 477.04 89 999999999 418.08 509.2 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; MINIMUM OF 3 VIEWS" 9513040_50_1 CDM 320 RC 73130 HCPCS outpatient 536 402 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 471.68 88 999999999 418.08 509.2 percent of total billed charges "RADIOLOGIC EXAMINATION, HAND; MINIMUM OF 3 VIEWS" 9513040_50_1 CDM 320 RC 73130 HCPCS outpatient 536 402 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 477.04 89 999999999 418.08 509.2 percent of total billed charges "RADIOLOGIC EXAMINATION, FINGER(S), MINIMUM OF 2 VIEWS" 9513043_1 CDM 320 RC 73140 HCPCS outpatient 258 193.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 232.2 90 999999999 201.24 245.1 percent of total billed charges "RADIOLOGIC EXAMINATION, FINGER(S), MINIMUM OF 2 VIEWS" 9513043_1 CDM 320 RC 73140 HCPCS outpatient 258 193.5 AETNA MCR ADV AETNA MCR ADV 201.24 78 999999999 201.24 245.1 percent of total billed charges "RADIOLOGIC EXAMINATION, FINGER(S), MINIMUM OF 2 VIEWS" 9513043_1 CDM 320 RC 73140 HCPCS outpatient 258 193.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 225.93 87.57 999999999 201.24 245.1 percent of total billed charges "RADIOLOGIC EXAMINATION, FINGER(S), MINIMUM OF 2 VIEWS" 9513043_1 CDM 320 RC 73140 HCPCS outpatient 258 193.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 219.48 85.07 999999999 201.24 245.1 percent of total billed charges "RADIOLOGIC EXAMINATION, FINGER(S), MINIMUM OF 2 VIEWS" 9513043_1 CDM 320 RC 73140 HCPCS outpatient 258 193.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 219.48 85.07 999999999 201.24 245.1 percent of total billed charges "RADIOLOGIC EXAMINATION, FINGER(S), MINIMUM OF 2 VIEWS" 9513043_1 CDM 320 RC 73140 HCPCS outpatient 258 193.5 MOLINA MCAID MOLINA MCAID 215.17 83.4 999999999 201.24 245.1 percent of total billed charges "RADIOLOGIC EXAMINATION, FINGER(S), MINIMUM OF 2 VIEWS" 9513043_1 CDM 320 RC 73140 HCPCS outpatient 258 193.5 MOLINA MCR ADV MOLINA MCR ADV 229.62 89 999999999 201.24 245.1 percent of total billed charges "RADIOLOGIC EXAMINATION, FINGER(S), MINIMUM OF 2 VIEWS" 9513043_1 CDM 320 RC 73140 HCPCS outpatient 258 193.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 229.62 89 999999999 201.24 245.1 percent of total billed charges "RADIOLOGIC EXAMINATION, FINGER(S), MINIMUM OF 2 VIEWS" 9513043_1 CDM 320 RC 73140 HCPCS outpatient 258 193.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 229.62 89 999999999 201.24 245.1 percent of total billed charges "RADIOLOGIC EXAMINATION, FINGER(S), MINIMUM OF 2 VIEWS" 9513043_1 CDM 320 RC 73140 HCPCS outpatient 258 193.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 232.2 90 999999999 201.24 245.1 percent of total billed charges "RADIOLOGIC EXAMINATION, FINGER(S), MINIMUM OF 2 VIEWS" 9513043_1 CDM 320 RC 73140 HCPCS outpatient 258 193.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 245.1 95 999999999 201.24 245.1 percent of total billed charges "RADIOLOGIC EXAMINATION, FINGER(S), MINIMUM OF 2 VIEWS" 9513043_1 CDM 320 RC 73140 HCPCS outpatient 258 193.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 245.1 95 999999999 201.24 245.1 percent of total billed charges "RADIOLOGIC EXAMINATION, FINGER(S), MINIMUM OF 2 VIEWS" 9513043_1 CDM 320 RC 73140 HCPCS outpatient 258 193.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 229.62 89 999999999 201.24 245.1 percent of total billed charges "RADIOLOGIC EXAMINATION, FINGER(S), MINIMUM OF 2 VIEWS" 9513043_1 CDM 320 RC 73140 HCPCS outpatient 258 193.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 227.04 88 999999999 201.24 245.1 percent of total billed charges "RADIOLOGIC EXAMINATION, FINGER(S), MINIMUM OF 2 VIEWS" 9513043_1 CDM 320 RC 73140 HCPCS outpatient 258 193.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 229.62 89 999999999 201.24 245.1 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513046_1 CDM 352 RC 73200 HCPCS outpatient 1599 1199.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1439.1 90 999999999 1247.22 1519.05 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513046_1 CDM 352 RC 73200 HCPCS outpatient 1599 1199.25 AETNA MCR ADV AETNA MCR ADV 1247.22 78 999999999 1247.22 1519.05 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513046_1 CDM 352 RC 73200 HCPCS outpatient 1599 1199.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1400.24 87.57 999999999 1247.22 1519.05 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513046_1 CDM 352 RC 73200 HCPCS outpatient 1599 1199.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 1360.27 85.07 999999999 1247.22 1519.05 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513046_1 CDM 352 RC 73200 HCPCS outpatient 1599 1199.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1360.27 85.07 999999999 1247.22 1519.05 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513046_1 CDM 352 RC 73200 HCPCS outpatient 1599 1199.25 MOLINA MCAID MOLINA MCAID 1333.57 83.4 999999999 1247.22 1519.05 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513046_1 CDM 352 RC 73200 HCPCS outpatient 1599 1199.25 MOLINA MCR ADV MOLINA MCR ADV 1423.11 89 999999999 1247.22 1519.05 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513046_1 CDM 352 RC 73200 HCPCS outpatient 1599 1199.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1423.11 89 999999999 1247.22 1519.05 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513046_1 CDM 352 RC 73200 HCPCS outpatient 1599 1199.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1423.11 89 999999999 1247.22 1519.05 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513046_1 CDM 352 RC 73200 HCPCS outpatient 1599 1199.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1439.1 90 999999999 1247.22 1519.05 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513046_1 CDM 352 RC 73200 HCPCS outpatient 1599 1199.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1519.05 95 999999999 1247.22 1519.05 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513046_1 CDM 352 RC 73200 HCPCS outpatient 1599 1199.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1519.05 95 999999999 1247.22 1519.05 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513046_1 CDM 352 RC 73200 HCPCS outpatient 1599 1199.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1423.11 89 999999999 1247.22 1519.05 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513046_1 CDM 352 RC 73200 HCPCS outpatient 1599 1199.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1407.12 88 999999999 1247.22 1519.05 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513046_1 CDM 352 RC 73200 HCPCS outpatient 1599 1199.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1423.11 89 999999999 1247.22 1519.05 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITH CONTRAST MATERIAL(S)" 9513049_1 CDM 352 RC 73201 HCPCS outpatient 1924 1443 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1731.6 90 999999999 1500.72 1827.8 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITH CONTRAST MATERIAL(S)" 9513049_1 CDM 352 RC 73201 HCPCS outpatient 1924 1443 AETNA MCR ADV AETNA MCR ADV 1500.72 78 999999999 1500.72 1827.8 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITH CONTRAST MATERIAL(S)" 9513049_1 CDM 352 RC 73201 HCPCS outpatient 1924 1443 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1684.85 87.57 999999999 1500.72 1827.8 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITH CONTRAST MATERIAL(S)" 9513049_1 CDM 352 RC 73201 HCPCS outpatient 1924 1443 COORDINATED CARE MCAID COORDINATED CARE MCAID 1636.75 85.07 999999999 1500.72 1827.8 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITH CONTRAST MATERIAL(S)" 9513049_1 CDM 352 RC 73201 HCPCS outpatient 1924 1443 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1636.75 85.07 999999999 1500.72 1827.8 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITH CONTRAST MATERIAL(S)" 9513049_1 CDM 352 RC 73201 HCPCS outpatient 1924 1443 MOLINA MCAID MOLINA MCAID 1604.62 83.4 999999999 1500.72 1827.8 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITH CONTRAST MATERIAL(S)" 9513049_1 CDM 352 RC 73201 HCPCS outpatient 1924 1443 MOLINA MCR ADV MOLINA MCR ADV 1712.36 89 999999999 1500.72 1827.8 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITH CONTRAST MATERIAL(S)" 9513049_1 CDM 352 RC 73201 HCPCS outpatient 1924 1443 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1712.36 89 999999999 1500.72 1827.8 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITH CONTRAST MATERIAL(S)" 9513049_1 CDM 352 RC 73201 HCPCS outpatient 1924 1443 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1712.36 89 999999999 1500.72 1827.8 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITH CONTRAST MATERIAL(S)" 9513049_1 CDM 352 RC 73201 HCPCS outpatient 1924 1443 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1731.6 90 999999999 1500.72 1827.8 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITH CONTRAST MATERIAL(S)" 9513049_1 CDM 352 RC 73201 HCPCS outpatient 1924 1443 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1827.8 95 999999999 1500.72 1827.8 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITH CONTRAST MATERIAL(S)" 9513049_1 CDM 352 RC 73201 HCPCS outpatient 1924 1443 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1827.8 95 999999999 1500.72 1827.8 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITH CONTRAST MATERIAL(S)" 9513049_1 CDM 352 RC 73201 HCPCS outpatient 1924 1443 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1712.36 89 999999999 1500.72 1827.8 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITH CONTRAST MATERIAL(S)" 9513049_1 CDM 352 RC 73201 HCPCS outpatient 1924 1443 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1693.12 88 999999999 1500.72 1827.8 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITH CONTRAST MATERIAL(S)" 9513049_1 CDM 352 RC 73201 HCPCS outpatient 1924 1443 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1712.36 89 999999999 1500.72 1827.8 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513052_1 CDM 352 RC 73202 HCPCS outpatient 2436 1827 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 2192.4 90 999999999 1900.08 2314.2 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513052_1 CDM 352 RC 73202 HCPCS outpatient 2436 1827 AETNA MCR ADV AETNA MCR ADV 1900.08 78 999999999 1900.08 2314.2 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513052_1 CDM 352 RC 73202 HCPCS outpatient 2436 1827 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 2133.21 87.57 999999999 1900.08 2314.2 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513052_1 CDM 352 RC 73202 HCPCS outpatient 2436 1827 COORDINATED CARE MCAID COORDINATED CARE MCAID 2072.31 85.07 999999999 1900.08 2314.2 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513052_1 CDM 352 RC 73202 HCPCS outpatient 2436 1827 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 2072.31 85.07 999999999 1900.08 2314.2 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513052_1 CDM 352 RC 73202 HCPCS outpatient 2436 1827 MOLINA MCAID MOLINA MCAID 2031.62 83.4 999999999 1900.08 2314.2 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513052_1 CDM 352 RC 73202 HCPCS outpatient 2436 1827 MOLINA MCR ADV MOLINA MCR ADV 2168.04 89 999999999 1900.08 2314.2 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513052_1 CDM 352 RC 73202 HCPCS outpatient 2436 1827 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 2168.04 89 999999999 1900.08 2314.2 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513052_1 CDM 352 RC 73202 HCPCS outpatient 2436 1827 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 2168.04 89 999999999 1900.08 2314.2 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513052_1 CDM 352 RC 73202 HCPCS outpatient 2436 1827 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 2192.4 90 999999999 1900.08 2314.2 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513052_1 CDM 352 RC 73202 HCPCS outpatient 2436 1827 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 2314.2 95 999999999 1900.08 2314.2 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513052_1 CDM 352 RC 73202 HCPCS outpatient 2436 1827 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 2314.2 95 999999999 1900.08 2314.2 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513052_1 CDM 352 RC 73202 HCPCS outpatient 2436 1827 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 2168.04 89 999999999 1900.08 2314.2 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513052_1 CDM 352 RC 73202 HCPCS outpatient 2436 1827 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 2143.68 88 999999999 1900.08 2314.2 percent of total billed charges "COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513052_1 CDM 352 RC 73202 HCPCS outpatient 2436 1827 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 2168.04 89 999999999 1900.08 2314.2 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S)" 9513058_1 CDM 610 RC 73218 HCPCS outpatient 2095 1571.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1885.5 90 999999999 1634.1 1990.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S)" 9513058_1 CDM 610 RC 73218 HCPCS outpatient 2095 1571.25 AETNA MCR ADV AETNA MCR ADV 1634.1 78 999999999 1634.1 1990.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S)" 9513058_1 CDM 610 RC 73218 HCPCS outpatient 2095 1571.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1834.59 87.57 999999999 1634.1 1990.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S)" 9513058_1 CDM 610 RC 73218 HCPCS outpatient 2095 1571.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 1782.22 85.07 999999999 1634.1 1990.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S)" 9513058_1 CDM 610 RC 73218 HCPCS outpatient 2095 1571.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1782.22 85.07 999999999 1634.1 1990.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S)" 9513058_1 CDM 610 RC 73218 HCPCS outpatient 2095 1571.25 MOLINA MCAID MOLINA MCAID 1747.23 83.4 999999999 1634.1 1990.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S)" 9513058_1 CDM 610 RC 73218 HCPCS outpatient 2095 1571.25 MOLINA MCR ADV MOLINA MCR ADV 1864.55 89 999999999 1634.1 1990.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S)" 9513058_1 CDM 610 RC 73218 HCPCS outpatient 2095 1571.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1864.55 89 999999999 1634.1 1990.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S)" 9513058_1 CDM 610 RC 73218 HCPCS outpatient 2095 1571.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1864.55 89 999999999 1634.1 1990.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S)" 9513058_1 CDM 610 RC 73218 HCPCS outpatient 2095 1571.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1885.5 90 999999999 1634.1 1990.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S)" 9513058_1 CDM 610 RC 73218 HCPCS outpatient 2095 1571.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1990.25 95 999999999 1634.1 1990.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S)" 9513058_1 CDM 610 RC 73218 HCPCS outpatient 2095 1571.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1990.25 95 999999999 1634.1 1990.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S)" 9513058_1 CDM 610 RC 73218 HCPCS outpatient 2095 1571.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1864.55 89 999999999 1634.1 1990.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S)" 9513058_1 CDM 610 RC 73218 HCPCS outpatient 2095 1571.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1843.6 88 999999999 1634.1 1990.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S)" 9513058_1 CDM 610 RC 73218 HCPCS outpatient 2095 1571.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1864.55 89 999999999 1634.1 1990.25 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9513064_1 CDM 610 RC 73220 HCPCS outpatient 2800 2100 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 2520 90 999999999 2184 2660 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9513064_1 CDM 610 RC 73220 HCPCS outpatient 2800 2100 AETNA MCR ADV AETNA MCR ADV 2184 78 999999999 2184 2660 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9513064_1 CDM 610 RC 73220 HCPCS outpatient 2800 2100 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 2451.96 87.57 999999999 2184 2660 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9513064_1 CDM 610 RC 73220 HCPCS outpatient 2800 2100 COORDINATED CARE MCAID COORDINATED CARE MCAID 2381.96 85.07 999999999 2184 2660 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9513064_1 CDM 610 RC 73220 HCPCS outpatient 2800 2100 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 2381.96 85.07 999999999 2184 2660 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9513064_1 CDM 610 RC 73220 HCPCS outpatient 2800 2100 MOLINA MCAID MOLINA MCAID 2335.2 83.4 999999999 2184 2660 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9513064_1 CDM 610 RC 73220 HCPCS outpatient 2800 2100 MOLINA MCR ADV MOLINA MCR ADV 2492 89 999999999 2184 2660 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9513064_1 CDM 610 RC 73220 HCPCS outpatient 2800 2100 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 2492 89 999999999 2184 2660 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9513064_1 CDM 610 RC 73220 HCPCS outpatient 2800 2100 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 2492 89 999999999 2184 2660 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9513064_1 CDM 610 RC 73220 HCPCS outpatient 2800 2100 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 2520 90 999999999 2184 2660 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9513064_1 CDM 610 RC 73220 HCPCS outpatient 2800 2100 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 2660 95 999999999 2184 2660 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9513064_1 CDM 610 RC 73220 HCPCS outpatient 2800 2100 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 2660 95 999999999 2184 2660 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9513064_1 CDM 610 RC 73220 HCPCS outpatient 2800 2100 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 2492 89 999999999 2184 2660 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9513064_1 CDM 610 RC 73220 HCPCS outpatient 2800 2100 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 2464 88 999999999 2184 2660 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9513064_1 CDM 610 RC 73220 HCPCS outpatient 2800 2100 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 2492 89 999999999 2184 2660 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL(S)" 9513067_1 CDM 610 RC 73221 HCPCS outpatient 2251 1688.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 2025.9 90 999999999 1755.78 2138.45 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL(S)" 9513067_1 CDM 610 RC 73221 HCPCS outpatient 2251 1688.25 AETNA MCR ADV AETNA MCR ADV 1755.78 78 999999999 1755.78 2138.45 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL(S)" 9513067_1 CDM 610 RC 73221 HCPCS outpatient 2251 1688.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1971.2 87.57 999999999 1755.78 2138.45 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL(S)" 9513067_1 CDM 610 RC 73221 HCPCS outpatient 2251 1688.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 1914.93 85.07 999999999 1755.78 2138.45 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL(S)" 9513067_1 CDM 610 RC 73221 HCPCS outpatient 2251 1688.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1914.93 85.07 999999999 1755.78 2138.45 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL(S)" 9513067_1 CDM 610 RC 73221 HCPCS outpatient 2251 1688.25 MOLINA MCAID MOLINA MCAID 1877.33 83.4 999999999 1755.78 2138.45 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL(S)" 9513067_1 CDM 610 RC 73221 HCPCS outpatient 2251 1688.25 MOLINA MCR ADV MOLINA MCR ADV 2003.39 89 999999999 1755.78 2138.45 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL(S)" 9513067_1 CDM 610 RC 73221 HCPCS outpatient 2251 1688.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 2003.39 89 999999999 1755.78 2138.45 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL(S)" 9513067_1 CDM 610 RC 73221 HCPCS outpatient 2251 1688.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 2003.39 89 999999999 1755.78 2138.45 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL(S)" 9513067_1 CDM 610 RC 73221 HCPCS outpatient 2251 1688.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 2025.9 90 999999999 1755.78 2138.45 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL(S)" 9513067_1 CDM 610 RC 73221 HCPCS outpatient 2251 1688.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 2138.45 95 999999999 1755.78 2138.45 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL(S)" 9513067_1 CDM 610 RC 73221 HCPCS outpatient 2251 1688.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 2138.45 95 999999999 1755.78 2138.45 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL(S)" 9513067_1 CDM 610 RC 73221 HCPCS outpatient 2251 1688.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 2003.39 89 999999999 1755.78 2138.45 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL(S)" 9513067_1 CDM 610 RC 73221 HCPCS outpatient 2251 1688.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1980.88 88 999999999 1755.78 2138.45 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL(S)" 9513067_1 CDM 610 RC 73221 HCPCS outpatient 2251 1688.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 2003.39 89 999999999 1755.78 2138.45 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; 1 OR 2 VIEWS" 9513100_1 CDM 320 RC 73560 HCPCS outpatient 284 213 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 255.6 90 999999999 221.52 269.8 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; 1 OR 2 VIEWS" 9513100_1 CDM 320 RC 73560 HCPCS outpatient 284 213 AETNA MCR ADV AETNA MCR ADV 221.52 78 999999999 221.52 269.8 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; 1 OR 2 VIEWS" 9513100_1 CDM 320 RC 73560 HCPCS outpatient 284 213 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 248.7 87.57 999999999 221.52 269.8 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; 1 OR 2 VIEWS" 9513100_1 CDM 320 RC 73560 HCPCS outpatient 284 213 COORDINATED CARE MCAID COORDINATED CARE MCAID 241.6 85.07 999999999 221.52 269.8 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; 1 OR 2 VIEWS" 9513100_1 CDM 320 RC 73560 HCPCS outpatient 284 213 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 241.6 85.07 999999999 221.52 269.8 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; 1 OR 2 VIEWS" 9513100_1 CDM 320 RC 73560 HCPCS outpatient 284 213 MOLINA MCAID MOLINA MCAID 236.86 83.4 999999999 221.52 269.8 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; 1 OR 2 VIEWS" 9513100_1 CDM 320 RC 73560 HCPCS outpatient 284 213 MOLINA MCR ADV MOLINA MCR ADV 252.76 89 999999999 221.52 269.8 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; 1 OR 2 VIEWS" 9513100_1 CDM 320 RC 73560 HCPCS outpatient 284 213 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 252.76 89 999999999 221.52 269.8 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; 1 OR 2 VIEWS" 9513100_1 CDM 320 RC 73560 HCPCS outpatient 284 213 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 252.76 89 999999999 221.52 269.8 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; 1 OR 2 VIEWS" 9513100_1 CDM 320 RC 73560 HCPCS outpatient 284 213 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 255.6 90 999999999 221.52 269.8 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; 1 OR 2 VIEWS" 9513100_1 CDM 320 RC 73560 HCPCS outpatient 284 213 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 269.8 95 999999999 221.52 269.8 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; 1 OR 2 VIEWS" 9513100_1 CDM 320 RC 73560 HCPCS outpatient 284 213 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 269.8 95 999999999 221.52 269.8 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; 1 OR 2 VIEWS" 9513100_1 CDM 320 RC 73560 HCPCS outpatient 284 213 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 252.76 89 999999999 221.52 269.8 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; 1 OR 2 VIEWS" 9513100_1 CDM 320 RC 73560 HCPCS outpatient 284 213 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 249.92 88 999999999 221.52 269.8 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; 1 OR 2 VIEWS" 9513100_1 CDM 320 RC 73560 HCPCS outpatient 284 213 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 252.76 89 999999999 221.52 269.8 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; 3 VIEWS" 9513103_1 CDM 320 RC 73562 HCPCS outpatient 438 328.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 394.2 90 999999999 341.64 416.1 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; 3 VIEWS" 9513103_1 CDM 320 RC 73562 HCPCS outpatient 438 328.5 AETNA MCR ADV AETNA MCR ADV 341.64 78 999999999 341.64 416.1 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; 3 VIEWS" 9513103_1 CDM 320 RC 73562 HCPCS outpatient 438 328.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 383.56 87.57 999999999 341.64 416.1 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; 3 VIEWS" 9513103_1 CDM 320 RC 73562 HCPCS outpatient 438 328.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 372.61 85.07 999999999 341.64 416.1 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; 3 VIEWS" 9513103_1 CDM 320 RC 73562 HCPCS outpatient 438 328.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 372.61 85.07 999999999 341.64 416.1 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; 3 VIEWS" 9513103_1 CDM 320 RC 73562 HCPCS outpatient 438 328.5 MOLINA MCAID MOLINA MCAID 365.29 83.4 999999999 341.64 416.1 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; 3 VIEWS" 9513103_1 CDM 320 RC 73562 HCPCS outpatient 438 328.5 MOLINA MCR ADV MOLINA MCR ADV 389.82 89 999999999 341.64 416.1 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; 3 VIEWS" 9513103_1 CDM 320 RC 73562 HCPCS outpatient 438 328.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 389.82 89 999999999 341.64 416.1 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; 3 VIEWS" 9513103_1 CDM 320 RC 73562 HCPCS outpatient 438 328.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 389.82 89 999999999 341.64 416.1 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; 3 VIEWS" 9513103_1 CDM 320 RC 73562 HCPCS outpatient 438 328.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 394.2 90 999999999 341.64 416.1 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; 3 VIEWS" 9513103_1 CDM 320 RC 73562 HCPCS outpatient 438 328.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 416.1 95 999999999 341.64 416.1 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; 3 VIEWS" 9513103_1 CDM 320 RC 73562 HCPCS outpatient 438 328.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 416.1 95 999999999 341.64 416.1 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; 3 VIEWS" 9513103_1 CDM 320 RC 73562 HCPCS outpatient 438 328.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 389.82 89 999999999 341.64 416.1 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; 3 VIEWS" 9513103_1 CDM 320 RC 73562 HCPCS outpatient 438 328.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 385.44 88 999999999 341.64 416.1 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; 3 VIEWS" 9513103_1 CDM 320 RC 73562 HCPCS outpatient 438 328.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 389.82 89 999999999 341.64 416.1 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; COMPLETE, 4 OR MORE VIEWS" 9513106_1 CDM 320 RC 73564 HCPCS outpatient 408 306 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 367.2 90 999999999 318.24 387.6 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; COMPLETE, 4 OR MORE VIEWS" 9513106_1 CDM 320 RC 73564 HCPCS outpatient 408 306 AETNA MCR ADV AETNA MCR ADV 318.24 78 999999999 318.24 387.6 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; COMPLETE, 4 OR MORE VIEWS" 9513106_1 CDM 320 RC 73564 HCPCS outpatient 408 306 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 357.29 87.57 999999999 318.24 387.6 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; COMPLETE, 4 OR MORE VIEWS" 9513106_1 CDM 320 RC 73564 HCPCS outpatient 408 306 COORDINATED CARE MCAID COORDINATED CARE MCAID 347.09 85.07 999999999 318.24 387.6 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; COMPLETE, 4 OR MORE VIEWS" 9513106_1 CDM 320 RC 73564 HCPCS outpatient 408 306 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 347.09 85.07 999999999 318.24 387.6 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; COMPLETE, 4 OR MORE VIEWS" 9513106_1 CDM 320 RC 73564 HCPCS outpatient 408 306 MOLINA MCAID MOLINA MCAID 340.27 83.4 999999999 318.24 387.6 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; COMPLETE, 4 OR MORE VIEWS" 9513106_1 CDM 320 RC 73564 HCPCS outpatient 408 306 MOLINA MCR ADV MOLINA MCR ADV 363.12 89 999999999 318.24 387.6 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; COMPLETE, 4 OR MORE VIEWS" 9513106_1 CDM 320 RC 73564 HCPCS outpatient 408 306 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 363.12 89 999999999 318.24 387.6 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; COMPLETE, 4 OR MORE VIEWS" 9513106_1 CDM 320 RC 73564 HCPCS outpatient 408 306 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 363.12 89 999999999 318.24 387.6 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; COMPLETE, 4 OR MORE VIEWS" 9513106_1 CDM 320 RC 73564 HCPCS outpatient 408 306 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 367.2 90 999999999 318.24 387.6 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; COMPLETE, 4 OR MORE VIEWS" 9513106_1 CDM 320 RC 73564 HCPCS outpatient 408 306 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 387.6 95 999999999 318.24 387.6 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; COMPLETE, 4 OR MORE VIEWS" 9513106_1 CDM 320 RC 73564 HCPCS outpatient 408 306 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 387.6 95 999999999 318.24 387.6 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; COMPLETE, 4 OR MORE VIEWS" 9513106_1 CDM 320 RC 73564 HCPCS outpatient 408 306 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 363.12 89 999999999 318.24 387.6 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; COMPLETE, 4 OR MORE VIEWS" 9513106_1 CDM 320 RC 73564 HCPCS outpatient 408 306 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 359.04 88 999999999 318.24 387.6 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; COMPLETE, 4 OR MORE VIEWS" 9513106_1 CDM 320 RC 73564 HCPCS outpatient 408 306 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 363.12 89 999999999 318.24 387.6 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; BOTH KNEES, STANDING, ANTEROPOSTERIOR" 9513109_1 CDM 320 RC 73565 HCPCS outpatient 700 525 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 630 90 999999999 546 665 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; BOTH KNEES, STANDING, ANTEROPOSTERIOR" 9513109_1 CDM 320 RC 73565 HCPCS outpatient 700 525 AETNA MCR ADV AETNA MCR ADV 546 78 999999999 546 665 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; BOTH KNEES, STANDING, ANTEROPOSTERIOR" 9513109_1 CDM 320 RC 73565 HCPCS outpatient 700 525 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 612.99 87.57 999999999 546 665 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; BOTH KNEES, STANDING, ANTEROPOSTERIOR" 9513109_1 CDM 320 RC 73565 HCPCS outpatient 700 525 COORDINATED CARE MCAID COORDINATED CARE MCAID 595.49 85.07 999999999 546 665 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; BOTH KNEES, STANDING, ANTEROPOSTERIOR" 9513109_1 CDM 320 RC 73565 HCPCS outpatient 700 525 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 595.49 85.07 999999999 546 665 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; BOTH KNEES, STANDING, ANTEROPOSTERIOR" 9513109_1 CDM 320 RC 73565 HCPCS outpatient 700 525 MOLINA MCAID MOLINA MCAID 583.8 83.4 999999999 546 665 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; BOTH KNEES, STANDING, ANTEROPOSTERIOR" 9513109_1 CDM 320 RC 73565 HCPCS outpatient 700 525 MOLINA MCR ADV MOLINA MCR ADV 623 89 999999999 546 665 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; BOTH KNEES, STANDING, ANTEROPOSTERIOR" 9513109_1 CDM 320 RC 73565 HCPCS outpatient 700 525 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 623 89 999999999 546 665 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; BOTH KNEES, STANDING, ANTEROPOSTERIOR" 9513109_1 CDM 320 RC 73565 HCPCS outpatient 700 525 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 623 89 999999999 546 665 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; BOTH KNEES, STANDING, ANTEROPOSTERIOR" 9513109_1 CDM 320 RC 73565 HCPCS outpatient 700 525 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 630 90 999999999 546 665 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; BOTH KNEES, STANDING, ANTEROPOSTERIOR" 9513109_1 CDM 320 RC 73565 HCPCS outpatient 700 525 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 665 95 999999999 546 665 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; BOTH KNEES, STANDING, ANTEROPOSTERIOR" 9513109_1 CDM 320 RC 73565 HCPCS outpatient 700 525 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 665 95 999999999 546 665 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; BOTH KNEES, STANDING, ANTEROPOSTERIOR" 9513109_1 CDM 320 RC 73565 HCPCS outpatient 700 525 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 623 89 999999999 546 665 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; BOTH KNEES, STANDING, ANTEROPOSTERIOR" 9513109_1 CDM 320 RC 73565 HCPCS outpatient 700 525 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 616 88 999999999 546 665 percent of total billed charges "RADIOLOGIC EXAMINATION, KNEE; BOTH KNEES, STANDING, ANTEROPOSTERIOR" 9513109_1 CDM 320 RC 73565 HCPCS outpatient 700 525 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 623 89 999999999 546 665 percent of total billed charges "RADIOLOGIC EXAMINATION; TIBIA AND FIBULA, 2 VIEWS" 9513115_1 CDM 320 RC 73590 HCPCS outpatient 263 197.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 236.7 90 999999999 205.14 249.85 percent of total billed charges "RADIOLOGIC EXAMINATION; TIBIA AND FIBULA, 2 VIEWS" 9513115_1 CDM 320 RC 73590 HCPCS outpatient 263 197.25 AETNA MCR ADV AETNA MCR ADV 205.14 78 999999999 205.14 249.85 percent of total billed charges "RADIOLOGIC EXAMINATION; TIBIA AND FIBULA, 2 VIEWS" 9513115_1 CDM 320 RC 73590 HCPCS outpatient 263 197.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 230.31 87.57 999999999 205.14 249.85 percent of total billed charges "RADIOLOGIC EXAMINATION; TIBIA AND FIBULA, 2 VIEWS" 9513115_1 CDM 320 RC 73590 HCPCS outpatient 263 197.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 223.73 85.07 999999999 205.14 249.85 percent of total billed charges "RADIOLOGIC EXAMINATION; TIBIA AND FIBULA, 2 VIEWS" 9513115_1 CDM 320 RC 73590 HCPCS outpatient 263 197.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 223.73 85.07 999999999 205.14 249.85 percent of total billed charges "RADIOLOGIC EXAMINATION; TIBIA AND FIBULA, 2 VIEWS" 9513115_1 CDM 320 RC 73590 HCPCS outpatient 263 197.25 MOLINA MCAID MOLINA MCAID 219.34 83.4 999999999 205.14 249.85 percent of total billed charges "RADIOLOGIC EXAMINATION; TIBIA AND FIBULA, 2 VIEWS" 9513115_1 CDM 320 RC 73590 HCPCS outpatient 263 197.25 MOLINA MCR ADV MOLINA MCR ADV 234.07 89 999999999 205.14 249.85 percent of total billed charges "RADIOLOGIC EXAMINATION; TIBIA AND FIBULA, 2 VIEWS" 9513115_1 CDM 320 RC 73590 HCPCS outpatient 263 197.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 234.07 89 999999999 205.14 249.85 percent of total billed charges "RADIOLOGIC EXAMINATION; TIBIA AND FIBULA, 2 VIEWS" 9513115_1 CDM 320 RC 73590 HCPCS outpatient 263 197.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 234.07 89 999999999 205.14 249.85 percent of total billed charges "RADIOLOGIC EXAMINATION; TIBIA AND FIBULA, 2 VIEWS" 9513115_1 CDM 320 RC 73590 HCPCS outpatient 263 197.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 236.7 90 999999999 205.14 249.85 percent of total billed charges "RADIOLOGIC EXAMINATION; TIBIA AND FIBULA, 2 VIEWS" 9513115_1 CDM 320 RC 73590 HCPCS outpatient 263 197.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 249.85 95 999999999 205.14 249.85 percent of total billed charges "RADIOLOGIC EXAMINATION; TIBIA AND FIBULA, 2 VIEWS" 9513115_1 CDM 320 RC 73590 HCPCS outpatient 263 197.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 249.85 95 999999999 205.14 249.85 percent of total billed charges "RADIOLOGIC EXAMINATION; TIBIA AND FIBULA, 2 VIEWS" 9513115_1 CDM 320 RC 73590 HCPCS outpatient 263 197.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 234.07 89 999999999 205.14 249.85 percent of total billed charges "RADIOLOGIC EXAMINATION; TIBIA AND FIBULA, 2 VIEWS" 9513115_1 CDM 320 RC 73590 HCPCS outpatient 263 197.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 231.44 88 999999999 205.14 249.85 percent of total billed charges "RADIOLOGIC EXAMINATION; TIBIA AND FIBULA, 2 VIEWS" 9513115_1 CDM 320 RC 73590 HCPCS outpatient 263 197.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 234.07 89 999999999 205.14 249.85 percent of total billed charges "RADIOLOGIC EXAMINATION; LOWER EXTREMITY, INFANT, MINIMUM OF 2 VIEWS" 9513118_1 CDM 320 RC 73592 HCPCS outpatient 334 250.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 300.6 90 999999999 260.52 317.3 percent of total billed charges "RADIOLOGIC EXAMINATION; LOWER EXTREMITY, INFANT, MINIMUM OF 2 VIEWS" 9513118_1 CDM 320 RC 73592 HCPCS outpatient 334 250.5 AETNA MCR ADV AETNA MCR ADV 260.52 78 999999999 260.52 317.3 percent of total billed charges "RADIOLOGIC EXAMINATION; LOWER EXTREMITY, INFANT, MINIMUM OF 2 VIEWS" 9513118_1 CDM 320 RC 73592 HCPCS outpatient 334 250.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 292.48 87.57 999999999 260.52 317.3 percent of total billed charges "RADIOLOGIC EXAMINATION; LOWER EXTREMITY, INFANT, MINIMUM OF 2 VIEWS" 9513118_1 CDM 320 RC 73592 HCPCS outpatient 334 250.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 284.13 85.07 999999999 260.52 317.3 percent of total billed charges "RADIOLOGIC EXAMINATION; LOWER EXTREMITY, INFANT, MINIMUM OF 2 VIEWS" 9513118_1 CDM 320 RC 73592 HCPCS outpatient 334 250.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 284.13 85.07 999999999 260.52 317.3 percent of total billed charges "RADIOLOGIC EXAMINATION; LOWER EXTREMITY, INFANT, MINIMUM OF 2 VIEWS" 9513118_1 CDM 320 RC 73592 HCPCS outpatient 334 250.5 MOLINA MCAID MOLINA MCAID 278.56 83.4 999999999 260.52 317.3 percent of total billed charges "RADIOLOGIC EXAMINATION; LOWER EXTREMITY, INFANT, MINIMUM OF 2 VIEWS" 9513118_1 CDM 320 RC 73592 HCPCS outpatient 334 250.5 MOLINA MCR ADV MOLINA MCR ADV 297.26 89 999999999 260.52 317.3 percent of total billed charges "RADIOLOGIC EXAMINATION; LOWER EXTREMITY, INFANT, MINIMUM OF 2 VIEWS" 9513118_1 CDM 320 RC 73592 HCPCS outpatient 334 250.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 297.26 89 999999999 260.52 317.3 percent of total billed charges "RADIOLOGIC EXAMINATION; LOWER EXTREMITY, INFANT, MINIMUM OF 2 VIEWS" 9513118_1 CDM 320 RC 73592 HCPCS outpatient 334 250.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 297.26 89 999999999 260.52 317.3 percent of total billed charges "RADIOLOGIC EXAMINATION; LOWER EXTREMITY, INFANT, MINIMUM OF 2 VIEWS" 9513118_1 CDM 320 RC 73592 HCPCS outpatient 334 250.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 300.6 90 999999999 260.52 317.3 percent of total billed charges "RADIOLOGIC EXAMINATION; LOWER EXTREMITY, INFANT, MINIMUM OF 2 VIEWS" 9513118_1 CDM 320 RC 73592 HCPCS outpatient 334 250.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 317.3 95 999999999 260.52 317.3 percent of total billed charges "RADIOLOGIC EXAMINATION; LOWER EXTREMITY, INFANT, MINIMUM OF 2 VIEWS" 9513118_1 CDM 320 RC 73592 HCPCS outpatient 334 250.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 317.3 95 999999999 260.52 317.3 percent of total billed charges "RADIOLOGIC EXAMINATION; LOWER EXTREMITY, INFANT, MINIMUM OF 2 VIEWS" 9513118_1 CDM 320 RC 73592 HCPCS outpatient 334 250.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 297.26 89 999999999 260.52 317.3 percent of total billed charges "RADIOLOGIC EXAMINATION; LOWER EXTREMITY, INFANT, MINIMUM OF 2 VIEWS" 9513118_1 CDM 320 RC 73592 HCPCS outpatient 334 250.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 293.92 88 999999999 260.52 317.3 percent of total billed charges "RADIOLOGIC EXAMINATION; LOWER EXTREMITY, INFANT, MINIMUM OF 2 VIEWS" 9513118_1 CDM 320 RC 73592 HCPCS outpatient 334 250.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 297.26 89 999999999 260.52 317.3 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; 2 VIEWS" 9513121_1 CDM 320 RC 73600 HCPCS outpatient 272 204 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 244.8 90 999999999 212.16 258.4 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; 2 VIEWS" 9513121_1 CDM 320 RC 73600 HCPCS outpatient 272 204 AETNA MCR ADV AETNA MCR ADV 212.16 78 999999999 212.16 258.4 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; 2 VIEWS" 9513121_1 CDM 320 RC 73600 HCPCS outpatient 272 204 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 238.19 87.57 999999999 212.16 258.4 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; 2 VIEWS" 9513121_1 CDM 320 RC 73600 HCPCS outpatient 272 204 COORDINATED CARE MCAID COORDINATED CARE MCAID 231.39 85.07 999999999 212.16 258.4 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; 2 VIEWS" 9513121_1 CDM 320 RC 73600 HCPCS outpatient 272 204 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 231.39 85.07 999999999 212.16 258.4 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; 2 VIEWS" 9513121_1 CDM 320 RC 73600 HCPCS outpatient 272 204 MOLINA MCAID MOLINA MCAID 226.85 83.4 999999999 212.16 258.4 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; 2 VIEWS" 9513121_1 CDM 320 RC 73600 HCPCS outpatient 272 204 MOLINA MCR ADV MOLINA MCR ADV 242.08 89 999999999 212.16 258.4 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; 2 VIEWS" 9513121_1 CDM 320 RC 73600 HCPCS outpatient 272 204 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 242.08 89 999999999 212.16 258.4 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; 2 VIEWS" 9513121_1 CDM 320 RC 73600 HCPCS outpatient 272 204 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 242.08 89 999999999 212.16 258.4 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; 2 VIEWS" 9513121_1 CDM 320 RC 73600 HCPCS outpatient 272 204 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 244.8 90 999999999 212.16 258.4 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; 2 VIEWS" 9513121_1 CDM 320 RC 73600 HCPCS outpatient 272 204 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 258.4 95 999999999 212.16 258.4 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; 2 VIEWS" 9513121_1 CDM 320 RC 73600 HCPCS outpatient 272 204 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 258.4 95 999999999 212.16 258.4 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; 2 VIEWS" 9513121_1 CDM 320 RC 73600 HCPCS outpatient 272 204 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 242.08 89 999999999 212.16 258.4 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; 2 VIEWS" 9513121_1 CDM 320 RC 73600 HCPCS outpatient 272 204 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 239.36 88 999999999 212.16 258.4 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; 2 VIEWS" 9513121_1 CDM 320 RC 73600 HCPCS outpatient 272 204 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 242.08 89 999999999 212.16 258.4 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF 3 VIEWS" 9513124_1 CDM 320 RC 73610 HCPCS outpatient 326 244.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 293.4 90 999999999 254.28 309.7 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF 3 VIEWS" 9513124_1 CDM 320 RC 73610 HCPCS outpatient 326 244.5 AETNA MCR ADV AETNA MCR ADV 254.28 78 999999999 254.28 309.7 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF 3 VIEWS" 9513124_1 CDM 320 RC 73610 HCPCS outpatient 326 244.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 285.48 87.57 999999999 254.28 309.7 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF 3 VIEWS" 9513124_1 CDM 320 RC 73610 HCPCS outpatient 326 244.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 277.33 85.07 999999999 254.28 309.7 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF 3 VIEWS" 9513124_1 CDM 320 RC 73610 HCPCS outpatient 326 244.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 277.33 85.07 999999999 254.28 309.7 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF 3 VIEWS" 9513124_1 CDM 320 RC 73610 HCPCS outpatient 326 244.5 MOLINA MCAID MOLINA MCAID 271.88 83.4 999999999 254.28 309.7 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF 3 VIEWS" 9513124_1 CDM 320 RC 73610 HCPCS outpatient 326 244.5 MOLINA MCR ADV MOLINA MCR ADV 290.14 89 999999999 254.28 309.7 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF 3 VIEWS" 9513124_1 CDM 320 RC 73610 HCPCS outpatient 326 244.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 290.14 89 999999999 254.28 309.7 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF 3 VIEWS" 9513124_1 CDM 320 RC 73610 HCPCS outpatient 326 244.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 290.14 89 999999999 254.28 309.7 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF 3 VIEWS" 9513124_1 CDM 320 RC 73610 HCPCS outpatient 326 244.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 293.4 90 999999999 254.28 309.7 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF 3 VIEWS" 9513124_1 CDM 320 RC 73610 HCPCS outpatient 326 244.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 309.7 95 999999999 254.28 309.7 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF 3 VIEWS" 9513124_1 CDM 320 RC 73610 HCPCS outpatient 326 244.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 309.7 95 999999999 254.28 309.7 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF 3 VIEWS" 9513124_1 CDM 320 RC 73610 HCPCS outpatient 326 244.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 290.14 89 999999999 254.28 309.7 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF 3 VIEWS" 9513124_1 CDM 320 RC 73610 HCPCS outpatient 326 244.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 286.88 88 999999999 254.28 309.7 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF 3 VIEWS" 9513124_1 CDM 320 RC 73610 HCPCS outpatient 326 244.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 290.14 89 999999999 254.28 309.7 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF 3 VIEWS" 9513124_50_1 CDM 320 RC 73610 HCPCS outpatient 489 366.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 440.1 90 999999999 381.42 464.55 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF 3 VIEWS" 9513124_50_1 CDM 320 RC 73610 HCPCS outpatient 489 366.75 AETNA MCR ADV AETNA MCR ADV 50 381.42 78 999999999 381.42 464.55 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF 3 VIEWS" 9513124_50_1 CDM 320 RC 73610 HCPCS outpatient 489 366.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 428.22 87.57 999999999 381.42 464.55 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF 3 VIEWS" 9513124_50_1 CDM 320 RC 73610 HCPCS outpatient 489 366.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 415.99 85.07 999999999 381.42 464.55 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF 3 VIEWS" 9513124_50_1 CDM 320 RC 73610 HCPCS outpatient 489 366.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 415.99 85.07 999999999 381.42 464.55 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF 3 VIEWS" 9513124_50_1 CDM 320 RC 73610 HCPCS outpatient 489 366.75 MOLINA MCAID MOLINA MCAID 50 407.83 83.4 999999999 381.42 464.55 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF 3 VIEWS" 9513124_50_1 CDM 320 RC 73610 HCPCS outpatient 489 366.75 MOLINA MCR ADV MOLINA MCR ADV 50 435.21 89 999999999 381.42 464.55 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF 3 VIEWS" 9513124_50_1 CDM 320 RC 73610 HCPCS outpatient 489 366.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 435.21 89 999999999 381.42 464.55 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF 3 VIEWS" 9513124_50_1 CDM 320 RC 73610 HCPCS outpatient 489 366.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 435.21 89 999999999 381.42 464.55 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF 3 VIEWS" 9513124_50_1 CDM 320 RC 73610 HCPCS outpatient 489 366.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 440.1 90 999999999 381.42 464.55 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF 3 VIEWS" 9513124_50_1 CDM 320 RC 73610 HCPCS outpatient 489 366.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 464.55 95 999999999 381.42 464.55 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF 3 VIEWS" 9513124_50_1 CDM 320 RC 73610 HCPCS outpatient 489 366.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 464.55 95 999999999 381.42 464.55 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF 3 VIEWS" 9513124_50_1 CDM 320 RC 73610 HCPCS outpatient 489 366.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 435.21 89 999999999 381.42 464.55 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF 3 VIEWS" 9513124_50_1 CDM 320 RC 73610 HCPCS outpatient 489 366.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 430.32 88 999999999 381.42 464.55 percent of total billed charges "RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF 3 VIEWS" 9513124_50_1 CDM 320 RC 73610 HCPCS outpatient 489 366.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 435.21 89 999999999 381.42 464.55 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; 2 VIEWS" 9513130_1 CDM 320 RC 73620 HCPCS outpatient 256 192 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 230.4 90 999999999 199.68 243.2 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; 2 VIEWS" 9513130_1 CDM 320 RC 73620 HCPCS outpatient 256 192 AETNA MCR ADV AETNA MCR ADV 199.68 78 999999999 199.68 243.2 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; 2 VIEWS" 9513130_1 CDM 320 RC 73620 HCPCS outpatient 256 192 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 224.18 87.57 999999999 199.68 243.2 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; 2 VIEWS" 9513130_1 CDM 320 RC 73620 HCPCS outpatient 256 192 COORDINATED CARE MCAID COORDINATED CARE MCAID 217.78 85.07 999999999 199.68 243.2 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; 2 VIEWS" 9513130_1 CDM 320 RC 73620 HCPCS outpatient 256 192 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 217.78 85.07 999999999 199.68 243.2 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; 2 VIEWS" 9513130_1 CDM 320 RC 73620 HCPCS outpatient 256 192 MOLINA MCAID MOLINA MCAID 213.5 83.4 999999999 199.68 243.2 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; 2 VIEWS" 9513130_1 CDM 320 RC 73620 HCPCS outpatient 256 192 MOLINA MCR ADV MOLINA MCR ADV 227.84 89 999999999 199.68 243.2 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; 2 VIEWS" 9513130_1 CDM 320 RC 73620 HCPCS outpatient 256 192 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 227.84 89 999999999 199.68 243.2 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; 2 VIEWS" 9513130_1 CDM 320 RC 73620 HCPCS outpatient 256 192 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 227.84 89 999999999 199.68 243.2 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; 2 VIEWS" 9513130_1 CDM 320 RC 73620 HCPCS outpatient 256 192 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 230.4 90 999999999 199.68 243.2 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; 2 VIEWS" 9513130_1 CDM 320 RC 73620 HCPCS outpatient 256 192 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 243.2 95 999999999 199.68 243.2 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; 2 VIEWS" 9513130_1 CDM 320 RC 73620 HCPCS outpatient 256 192 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 243.2 95 999999999 199.68 243.2 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; 2 VIEWS" 9513130_1 CDM 320 RC 73620 HCPCS outpatient 256 192 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 227.84 89 999999999 199.68 243.2 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; 2 VIEWS" 9513130_1 CDM 320 RC 73620 HCPCS outpatient 256 192 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 225.28 88 999999999 199.68 243.2 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; 2 VIEWS" 9513130_1 CDM 320 RC 73620 HCPCS outpatient 256 192 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 227.84 89 999999999 199.68 243.2 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; COMPLETE, MINIMUM OF 3 VIEWS" 9513133_1 CDM 320 RC 73630 HCPCS outpatient 318 238.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 286.2 90 999999999 248.04 302.1 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; COMPLETE, MINIMUM OF 3 VIEWS" 9513133_1 CDM 320 RC 73630 HCPCS outpatient 318 238.5 AETNA MCR ADV AETNA MCR ADV 248.04 78 999999999 248.04 302.1 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; COMPLETE, MINIMUM OF 3 VIEWS" 9513133_1 CDM 320 RC 73630 HCPCS outpatient 318 238.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 278.47 87.57 999999999 248.04 302.1 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; COMPLETE, MINIMUM OF 3 VIEWS" 9513133_1 CDM 320 RC 73630 HCPCS outpatient 318 238.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 270.52 85.07 999999999 248.04 302.1 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; COMPLETE, MINIMUM OF 3 VIEWS" 9513133_1 CDM 320 RC 73630 HCPCS outpatient 318 238.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 270.52 85.07 999999999 248.04 302.1 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; COMPLETE, MINIMUM OF 3 VIEWS" 9513133_1 CDM 320 RC 73630 HCPCS outpatient 318 238.5 MOLINA MCAID MOLINA MCAID 265.21 83.4 999999999 248.04 302.1 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; COMPLETE, MINIMUM OF 3 VIEWS" 9513133_1 CDM 320 RC 73630 HCPCS outpatient 318 238.5 MOLINA MCR ADV MOLINA MCR ADV 283.02 89 999999999 248.04 302.1 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; COMPLETE, MINIMUM OF 3 VIEWS" 9513133_1 CDM 320 RC 73630 HCPCS outpatient 318 238.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 283.02 89 999999999 248.04 302.1 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; COMPLETE, MINIMUM OF 3 VIEWS" 9513133_1 CDM 320 RC 73630 HCPCS outpatient 318 238.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 283.02 89 999999999 248.04 302.1 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; COMPLETE, MINIMUM OF 3 VIEWS" 9513133_1 CDM 320 RC 73630 HCPCS outpatient 318 238.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 286.2 90 999999999 248.04 302.1 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; COMPLETE, MINIMUM OF 3 VIEWS" 9513133_1 CDM 320 RC 73630 HCPCS outpatient 318 238.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 302.1 95 999999999 248.04 302.1 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; COMPLETE, MINIMUM OF 3 VIEWS" 9513133_1 CDM 320 RC 73630 HCPCS outpatient 318 238.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 302.1 95 999999999 248.04 302.1 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; COMPLETE, MINIMUM OF 3 VIEWS" 9513133_1 CDM 320 RC 73630 HCPCS outpatient 318 238.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 283.02 89 999999999 248.04 302.1 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; COMPLETE, MINIMUM OF 3 VIEWS" 9513133_1 CDM 320 RC 73630 HCPCS outpatient 318 238.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 279.84 88 999999999 248.04 302.1 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; COMPLETE, MINIMUM OF 3 VIEWS" 9513133_1 CDM 320 RC 73630 HCPCS outpatient 318 238.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 283.02 89 999999999 248.04 302.1 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; COMPLETE, MINIMUM OF 3 VIEWS" 9513133_50_1 CDM 320 RC 73630 HCPCS outpatient 477 357.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 429.3 90 999999999 372.06 453.15 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; COMPLETE, MINIMUM OF 3 VIEWS" 9513133_50_1 CDM 320 RC 73630 HCPCS outpatient 477 357.75 AETNA MCR ADV AETNA MCR ADV 50 372.06 78 999999999 372.06 453.15 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; COMPLETE, MINIMUM OF 3 VIEWS" 9513133_50_1 CDM 320 RC 73630 HCPCS outpatient 477 357.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 417.71 87.57 999999999 372.06 453.15 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; COMPLETE, MINIMUM OF 3 VIEWS" 9513133_50_1 CDM 320 RC 73630 HCPCS outpatient 477 357.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 405.78 85.07 999999999 372.06 453.15 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; COMPLETE, MINIMUM OF 3 VIEWS" 9513133_50_1 CDM 320 RC 73630 HCPCS outpatient 477 357.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 405.78 85.07 999999999 372.06 453.15 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; COMPLETE, MINIMUM OF 3 VIEWS" 9513133_50_1 CDM 320 RC 73630 HCPCS outpatient 477 357.75 MOLINA MCAID MOLINA MCAID 50 397.82 83.4 999999999 372.06 453.15 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; COMPLETE, MINIMUM OF 3 VIEWS" 9513133_50_1 CDM 320 RC 73630 HCPCS outpatient 477 357.75 MOLINA MCR ADV MOLINA MCR ADV 50 424.53 89 999999999 372.06 453.15 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; COMPLETE, MINIMUM OF 3 VIEWS" 9513133_50_1 CDM 320 RC 73630 HCPCS outpatient 477 357.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 424.53 89 999999999 372.06 453.15 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; COMPLETE, MINIMUM OF 3 VIEWS" 9513133_50_1 CDM 320 RC 73630 HCPCS outpatient 477 357.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 424.53 89 999999999 372.06 453.15 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; COMPLETE, MINIMUM OF 3 VIEWS" 9513133_50_1 CDM 320 RC 73630 HCPCS outpatient 477 357.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 429.3 90 999999999 372.06 453.15 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; COMPLETE, MINIMUM OF 3 VIEWS" 9513133_50_1 CDM 320 RC 73630 HCPCS outpatient 477 357.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 453.15 95 999999999 372.06 453.15 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; COMPLETE, MINIMUM OF 3 VIEWS" 9513133_50_1 CDM 320 RC 73630 HCPCS outpatient 477 357.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 453.15 95 999999999 372.06 453.15 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; COMPLETE, MINIMUM OF 3 VIEWS" 9513133_50_1 CDM 320 RC 73630 HCPCS outpatient 477 357.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 424.53 89 999999999 372.06 453.15 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; COMPLETE, MINIMUM OF 3 VIEWS" 9513133_50_1 CDM 320 RC 73630 HCPCS outpatient 477 357.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 419.76 88 999999999 372.06 453.15 percent of total billed charges "RADIOLOGIC EXAMINATION, FOOT; COMPLETE, MINIMUM OF 3 VIEWS" 9513133_50_1 CDM 320 RC 73630 HCPCS outpatient 477 357.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 424.53 89 999999999 372.06 453.15 percent of total billed charges "RADIOLOGIC EXAMINATION; CALCANEUS, MINIMUM OF 2 VIEWS" 9513136_1 CDM 320 RC 73650 HCPCS outpatient 248 186 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 223.2 90 999999999 193.44 235.6 percent of total billed charges "RADIOLOGIC EXAMINATION; CALCANEUS, MINIMUM OF 2 VIEWS" 9513136_1 CDM 320 RC 73650 HCPCS outpatient 248 186 AETNA MCR ADV AETNA MCR ADV 193.44 78 999999999 193.44 235.6 percent of total billed charges "RADIOLOGIC EXAMINATION; CALCANEUS, MINIMUM OF 2 VIEWS" 9513136_1 CDM 320 RC 73650 HCPCS outpatient 248 186 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 217.17 87.57 999999999 193.44 235.6 percent of total billed charges "RADIOLOGIC EXAMINATION; CALCANEUS, MINIMUM OF 2 VIEWS" 9513136_1 CDM 320 RC 73650 HCPCS outpatient 248 186 COORDINATED CARE MCAID COORDINATED CARE MCAID 210.97 85.07 999999999 193.44 235.6 percent of total billed charges "RADIOLOGIC EXAMINATION; CALCANEUS, MINIMUM OF 2 VIEWS" 9513136_1 CDM 320 RC 73650 HCPCS outpatient 248 186 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 210.97 85.07 999999999 193.44 235.6 percent of total billed charges "RADIOLOGIC EXAMINATION; CALCANEUS, MINIMUM OF 2 VIEWS" 9513136_1 CDM 320 RC 73650 HCPCS outpatient 248 186 MOLINA MCAID MOLINA MCAID 206.83 83.4 999999999 193.44 235.6 percent of total billed charges "RADIOLOGIC EXAMINATION; CALCANEUS, MINIMUM OF 2 VIEWS" 9513136_1 CDM 320 RC 73650 HCPCS outpatient 248 186 MOLINA MCR ADV MOLINA MCR ADV 220.72 89 999999999 193.44 235.6 percent of total billed charges "RADIOLOGIC EXAMINATION; CALCANEUS, MINIMUM OF 2 VIEWS" 9513136_1 CDM 320 RC 73650 HCPCS outpatient 248 186 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 220.72 89 999999999 193.44 235.6 percent of total billed charges "RADIOLOGIC EXAMINATION; CALCANEUS, MINIMUM OF 2 VIEWS" 9513136_1 CDM 320 RC 73650 HCPCS outpatient 248 186 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 220.72 89 999999999 193.44 235.6 percent of total billed charges "RADIOLOGIC EXAMINATION; CALCANEUS, MINIMUM OF 2 VIEWS" 9513136_1 CDM 320 RC 73650 HCPCS outpatient 248 186 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 223.2 90 999999999 193.44 235.6 percent of total billed charges "RADIOLOGIC EXAMINATION; CALCANEUS, MINIMUM OF 2 VIEWS" 9513136_1 CDM 320 RC 73650 HCPCS outpatient 248 186 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 235.6 95 999999999 193.44 235.6 percent of total billed charges "RADIOLOGIC EXAMINATION; CALCANEUS, MINIMUM OF 2 VIEWS" 9513136_1 CDM 320 RC 73650 HCPCS outpatient 248 186 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 235.6 95 999999999 193.44 235.6 percent of total billed charges "RADIOLOGIC EXAMINATION; CALCANEUS, MINIMUM OF 2 VIEWS" 9513136_1 CDM 320 RC 73650 HCPCS outpatient 248 186 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 220.72 89 999999999 193.44 235.6 percent of total billed charges "RADIOLOGIC EXAMINATION; CALCANEUS, MINIMUM OF 2 VIEWS" 9513136_1 CDM 320 RC 73650 HCPCS outpatient 248 186 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 218.24 88 999999999 193.44 235.6 percent of total billed charges "RADIOLOGIC EXAMINATION; CALCANEUS, MINIMUM OF 2 VIEWS" 9513136_1 CDM 320 RC 73650 HCPCS outpatient 248 186 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 220.72 89 999999999 193.44 235.6 percent of total billed charges "RADIOLOGIC EXAMINATION; TOE(S), MINIMUM OF 2 VIEWS" 9513139_1 CDM 320 RC 73660 HCPCS outpatient 414 310.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 372.6 90 999999999 322.92 393.3 percent of total billed charges "RADIOLOGIC EXAMINATION; TOE(S), MINIMUM OF 2 VIEWS" 9513139_1 CDM 320 RC 73660 HCPCS outpatient 414 310.5 AETNA MCR ADV AETNA MCR ADV 322.92 78 999999999 322.92 393.3 percent of total billed charges "RADIOLOGIC EXAMINATION; TOE(S), MINIMUM OF 2 VIEWS" 9513139_1 CDM 320 RC 73660 HCPCS outpatient 414 310.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 362.54 87.57 999999999 322.92 393.3 percent of total billed charges "RADIOLOGIC EXAMINATION; TOE(S), MINIMUM OF 2 VIEWS" 9513139_1 CDM 320 RC 73660 HCPCS outpatient 414 310.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 352.19 85.07 999999999 322.92 393.3 percent of total billed charges "RADIOLOGIC EXAMINATION; TOE(S), MINIMUM OF 2 VIEWS" 9513139_1 CDM 320 RC 73660 HCPCS outpatient 414 310.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 352.19 85.07 999999999 322.92 393.3 percent of total billed charges "RADIOLOGIC EXAMINATION; TOE(S), MINIMUM OF 2 VIEWS" 9513139_1 CDM 320 RC 73660 HCPCS outpatient 414 310.5 MOLINA MCAID MOLINA MCAID 345.28 83.4 999999999 322.92 393.3 percent of total billed charges "RADIOLOGIC EXAMINATION; TOE(S), MINIMUM OF 2 VIEWS" 9513139_1 CDM 320 RC 73660 HCPCS outpatient 414 310.5 MOLINA MCR ADV MOLINA MCR ADV 368.46 89 999999999 322.92 393.3 percent of total billed charges "RADIOLOGIC EXAMINATION; TOE(S), MINIMUM OF 2 VIEWS" 9513139_1 CDM 320 RC 73660 HCPCS outpatient 414 310.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 368.46 89 999999999 322.92 393.3 percent of total billed charges "RADIOLOGIC EXAMINATION; TOE(S), MINIMUM OF 2 VIEWS" 9513139_1 CDM 320 RC 73660 HCPCS outpatient 414 310.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 368.46 89 999999999 322.92 393.3 percent of total billed charges "RADIOLOGIC EXAMINATION; TOE(S), MINIMUM OF 2 VIEWS" 9513139_1 CDM 320 RC 73660 HCPCS outpatient 414 310.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 372.6 90 999999999 322.92 393.3 percent of total billed charges "RADIOLOGIC EXAMINATION; TOE(S), MINIMUM OF 2 VIEWS" 9513139_1 CDM 320 RC 73660 HCPCS outpatient 414 310.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 393.3 95 999999999 322.92 393.3 percent of total billed charges "RADIOLOGIC EXAMINATION; TOE(S), MINIMUM OF 2 VIEWS" 9513139_1 CDM 320 RC 73660 HCPCS outpatient 414 310.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 393.3 95 999999999 322.92 393.3 percent of total billed charges "RADIOLOGIC EXAMINATION; TOE(S), MINIMUM OF 2 VIEWS" 9513139_1 CDM 320 RC 73660 HCPCS outpatient 414 310.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 368.46 89 999999999 322.92 393.3 percent of total billed charges "RADIOLOGIC EXAMINATION; TOE(S), MINIMUM OF 2 VIEWS" 9513139_1 CDM 320 RC 73660 HCPCS outpatient 414 310.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 364.32 88 999999999 322.92 393.3 percent of total billed charges "RADIOLOGIC EXAMINATION; TOE(S), MINIMUM OF 2 VIEWS" 9513139_1 CDM 320 RC 73660 HCPCS outpatient 414 310.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 368.46 89 999999999 322.92 393.3 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513142_1 CDM 352 RC 73700 HCPCS outpatient 1472 1104 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1324.8 90 999999999 1148.16 1398.4 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513142_1 CDM 352 RC 73700 HCPCS outpatient 1472 1104 AETNA MCR ADV AETNA MCR ADV 1148.16 78 999999999 1148.16 1398.4 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513142_1 CDM 352 RC 73700 HCPCS outpatient 1472 1104 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1289.03 87.57 999999999 1148.16 1398.4 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513142_1 CDM 352 RC 73700 HCPCS outpatient 1472 1104 COORDINATED CARE MCAID COORDINATED CARE MCAID 1252.23 85.07 999999999 1148.16 1398.4 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513142_1 CDM 352 RC 73700 HCPCS outpatient 1472 1104 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1252.23 85.07 999999999 1148.16 1398.4 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513142_1 CDM 352 RC 73700 HCPCS outpatient 1472 1104 MOLINA MCAID MOLINA MCAID 1227.65 83.4 999999999 1148.16 1398.4 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513142_1 CDM 352 RC 73700 HCPCS outpatient 1472 1104 MOLINA MCR ADV MOLINA MCR ADV 1310.08 89 999999999 1148.16 1398.4 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513142_1 CDM 352 RC 73700 HCPCS outpatient 1472 1104 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1310.08 89 999999999 1148.16 1398.4 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513142_1 CDM 352 RC 73700 HCPCS outpatient 1472 1104 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1310.08 89 999999999 1148.16 1398.4 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513142_1 CDM 352 RC 73700 HCPCS outpatient 1472 1104 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1324.8 90 999999999 1148.16 1398.4 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513142_1 CDM 352 RC 73700 HCPCS outpatient 1472 1104 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1398.4 95 999999999 1148.16 1398.4 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513142_1 CDM 352 RC 73700 HCPCS outpatient 1472 1104 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1398.4 95 999999999 1148.16 1398.4 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513142_1 CDM 352 RC 73700 HCPCS outpatient 1472 1104 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1310.08 89 999999999 1148.16 1398.4 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513142_1 CDM 352 RC 73700 HCPCS outpatient 1472 1104 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1295.36 88 999999999 1148.16 1398.4 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513142_1 CDM 352 RC 73700 HCPCS outpatient 1472 1104 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1310.08 89 999999999 1148.16 1398.4 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITH CONTRAST MATERIAL(S)" 9513145_1 CDM 352 RC 73701 HCPCS outpatient 1923 1442.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1730.7 90 999999999 1499.94 1826.85 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITH CONTRAST MATERIAL(S)" 9513145_1 CDM 352 RC 73701 HCPCS outpatient 1923 1442.25 AETNA MCR ADV AETNA MCR ADV 1499.94 78 999999999 1499.94 1826.85 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITH CONTRAST MATERIAL(S)" 9513145_1 CDM 352 RC 73701 HCPCS outpatient 1923 1442.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1683.97 87.57 999999999 1499.94 1826.85 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITH CONTRAST MATERIAL(S)" 9513145_1 CDM 352 RC 73701 HCPCS outpatient 1923 1442.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 1635.9 85.07 999999999 1499.94 1826.85 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITH CONTRAST MATERIAL(S)" 9513145_1 CDM 352 RC 73701 HCPCS outpatient 1923 1442.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1635.9 85.07 999999999 1499.94 1826.85 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITH CONTRAST MATERIAL(S)" 9513145_1 CDM 352 RC 73701 HCPCS outpatient 1923 1442.25 MOLINA MCAID MOLINA MCAID 1603.78 83.4 999999999 1499.94 1826.85 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITH CONTRAST MATERIAL(S)" 9513145_1 CDM 352 RC 73701 HCPCS outpatient 1923 1442.25 MOLINA MCR ADV MOLINA MCR ADV 1711.47 89 999999999 1499.94 1826.85 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITH CONTRAST MATERIAL(S)" 9513145_1 CDM 352 RC 73701 HCPCS outpatient 1923 1442.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1711.47 89 999999999 1499.94 1826.85 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITH CONTRAST MATERIAL(S)" 9513145_1 CDM 352 RC 73701 HCPCS outpatient 1923 1442.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1711.47 89 999999999 1499.94 1826.85 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITH CONTRAST MATERIAL(S)" 9513145_1 CDM 352 RC 73701 HCPCS outpatient 1923 1442.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1730.7 90 999999999 1499.94 1826.85 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITH CONTRAST MATERIAL(S)" 9513145_1 CDM 352 RC 73701 HCPCS outpatient 1923 1442.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1826.85 95 999999999 1499.94 1826.85 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITH CONTRAST MATERIAL(S)" 9513145_1 CDM 352 RC 73701 HCPCS outpatient 1923 1442.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1826.85 95 999999999 1499.94 1826.85 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITH CONTRAST MATERIAL(S)" 9513145_1 CDM 352 RC 73701 HCPCS outpatient 1923 1442.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1711.47 89 999999999 1499.94 1826.85 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITH CONTRAST MATERIAL(S)" 9513145_1 CDM 352 RC 73701 HCPCS outpatient 1923 1442.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1692.24 88 999999999 1499.94 1826.85 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITH CONTRAST MATERIAL(S)" 9513145_1 CDM 352 RC 73701 HCPCS outpatient 1923 1442.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1711.47 89 999999999 1499.94 1826.85 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513148_1 CDM 352 RC 73702 HCPCS outpatient 2359 1769.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 2123.1 90 999999999 1840.02 2241.05 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513148_1 CDM 352 RC 73702 HCPCS outpatient 2359 1769.25 AETNA MCR ADV AETNA MCR ADV 1840.02 78 999999999 1840.02 2241.05 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513148_1 CDM 352 RC 73702 HCPCS outpatient 2359 1769.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 2065.78 87.57 999999999 1840.02 2241.05 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513148_1 CDM 352 RC 73702 HCPCS outpatient 2359 1769.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 2006.8 85.07 999999999 1840.02 2241.05 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513148_1 CDM 352 RC 73702 HCPCS outpatient 2359 1769.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 2006.8 85.07 999999999 1840.02 2241.05 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513148_1 CDM 352 RC 73702 HCPCS outpatient 2359 1769.25 MOLINA MCAID MOLINA MCAID 1967.41 83.4 999999999 1840.02 2241.05 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513148_1 CDM 352 RC 73702 HCPCS outpatient 2359 1769.25 MOLINA MCR ADV MOLINA MCR ADV 2099.51 89 999999999 1840.02 2241.05 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513148_1 CDM 352 RC 73702 HCPCS outpatient 2359 1769.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 2099.51 89 999999999 1840.02 2241.05 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513148_1 CDM 352 RC 73702 HCPCS outpatient 2359 1769.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 2099.51 89 999999999 1840.02 2241.05 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513148_1 CDM 352 RC 73702 HCPCS outpatient 2359 1769.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 2123.1 90 999999999 1840.02 2241.05 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513148_1 CDM 352 RC 73702 HCPCS outpatient 2359 1769.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 2241.05 95 999999999 1840.02 2241.05 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513148_1 CDM 352 RC 73702 HCPCS outpatient 2359 1769.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 2241.05 95 999999999 1840.02 2241.05 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513148_1 CDM 352 RC 73702 HCPCS outpatient 2359 1769.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 2099.51 89 999999999 1840.02 2241.05 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513148_1 CDM 352 RC 73702 HCPCS outpatient 2359 1769.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 2075.92 88 999999999 1840.02 2241.05 percent of total billed charges "COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513148_1 CDM 352 RC 73702 HCPCS outpatient 2359 1769.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 2099.51 89 999999999 1840.02 2241.05 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, LOWER EXTREMITY OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S)" 9513154_1 CDM 610 RC 73718 HCPCS outpatient 2484 1863 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 2235.6 90 999999999 1937.52 2359.8 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, LOWER EXTREMITY OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S)" 9513154_1 CDM 610 RC 73718 HCPCS outpatient 2484 1863 AETNA MCR ADV AETNA MCR ADV 1937.52 78 999999999 1937.52 2359.8 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, LOWER EXTREMITY OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S)" 9513154_1 CDM 610 RC 73718 HCPCS outpatient 2484 1863 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 2175.24 87.57 999999999 1937.52 2359.8 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, LOWER EXTREMITY OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S)" 9513154_1 CDM 610 RC 73718 HCPCS outpatient 2484 1863 COORDINATED CARE MCAID COORDINATED CARE MCAID 2113.14 85.07 999999999 1937.52 2359.8 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, LOWER EXTREMITY OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S)" 9513154_1 CDM 610 RC 73718 HCPCS outpatient 2484 1863 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 2113.14 85.07 999999999 1937.52 2359.8 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, LOWER EXTREMITY OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S)" 9513154_1 CDM 610 RC 73718 HCPCS outpatient 2484 1863 MOLINA MCAID MOLINA MCAID 2071.66 83.4 999999999 1937.52 2359.8 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, LOWER EXTREMITY OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S)" 9513154_1 CDM 610 RC 73718 HCPCS outpatient 2484 1863 MOLINA MCR ADV MOLINA MCR ADV 2210.76 89 999999999 1937.52 2359.8 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, LOWER EXTREMITY OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S)" 9513154_1 CDM 610 RC 73718 HCPCS outpatient 2484 1863 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 2210.76 89 999999999 1937.52 2359.8 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, LOWER EXTREMITY OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S)" 9513154_1 CDM 610 RC 73718 HCPCS outpatient 2484 1863 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 2210.76 89 999999999 1937.52 2359.8 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, LOWER EXTREMITY OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S)" 9513154_1 CDM 610 RC 73718 HCPCS outpatient 2484 1863 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 2235.6 90 999999999 1937.52 2359.8 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, LOWER EXTREMITY OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S)" 9513154_1 CDM 610 RC 73718 HCPCS outpatient 2484 1863 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 2359.8 95 999999999 1937.52 2359.8 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, LOWER EXTREMITY OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S)" 9513154_1 CDM 610 RC 73718 HCPCS outpatient 2484 1863 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 2359.8 95 999999999 1937.52 2359.8 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, LOWER EXTREMITY OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S)" 9513154_1 CDM 610 RC 73718 HCPCS outpatient 2484 1863 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 2210.76 89 999999999 1937.52 2359.8 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, LOWER EXTREMITY OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S)" 9513154_1 CDM 610 RC 73718 HCPCS outpatient 2484 1863 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 2185.92 88 999999999 1937.52 2359.8 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, LOWER EXTREMITY OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S)" 9513154_1 CDM 610 RC 73718 HCPCS outpatient 2484 1863 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 2210.76 89 999999999 1937.52 2359.8 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513163_1 CDM 610 RC 73721 HCPCS outpatient 2266 1699.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 2039.4 90 999999999 1767.48 2152.7 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513163_1 CDM 610 RC 73721 HCPCS outpatient 2266 1699.5 AETNA MCR ADV AETNA MCR ADV 1767.48 78 999999999 1767.48 2152.7 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513163_1 CDM 610 RC 73721 HCPCS outpatient 2266 1699.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1984.34 87.57 999999999 1767.48 2152.7 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513163_1 CDM 610 RC 73721 HCPCS outpatient 2266 1699.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 1927.69 85.07 999999999 1767.48 2152.7 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513163_1 CDM 610 RC 73721 HCPCS outpatient 2266 1699.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1927.69 85.07 999999999 1767.48 2152.7 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513163_1 CDM 610 RC 73721 HCPCS outpatient 2266 1699.5 MOLINA MCAID MOLINA MCAID 1889.84 83.4 999999999 1767.48 2152.7 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513163_1 CDM 610 RC 73721 HCPCS outpatient 2266 1699.5 MOLINA MCR ADV MOLINA MCR ADV 2016.74 89 999999999 1767.48 2152.7 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513163_1 CDM 610 RC 73721 HCPCS outpatient 2266 1699.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 2016.74 89 999999999 1767.48 2152.7 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513163_1 CDM 610 RC 73721 HCPCS outpatient 2266 1699.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 2016.74 89 999999999 1767.48 2152.7 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513163_1 CDM 610 RC 73721 HCPCS outpatient 2266 1699.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 2039.4 90 999999999 1767.48 2152.7 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513163_1 CDM 610 RC 73721 HCPCS outpatient 2266 1699.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 2152.7 95 999999999 1767.48 2152.7 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513163_1 CDM 610 RC 73721 HCPCS outpatient 2266 1699.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 2152.7 95 999999999 1767.48 2152.7 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513163_1 CDM 610 RC 73721 HCPCS outpatient 2266 1699.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 2016.74 89 999999999 1767.48 2152.7 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513163_1 CDM 610 RC 73721 HCPCS outpatient 2266 1699.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1994.08 88 999999999 1767.48 2152.7 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL" 9513163_1 CDM 610 RC 73721 HCPCS outpatient 2266 1699.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 2016.74 89 999999999 1767.48 2152.7 percent of total billed charges "RADIOLOGIC EXAMINATION, COMPLETE ACUTE ABDOMEN SERIES, INCLUDING 2 OR MORE VIEWS OF THE ABDOMEN (EG, SUPINE, ERECT, DECUBITUS), AND A SINGLE VIEW CHEST" 9513181_1 CDM 320 RC 74022 HCPCS outpatient 476 357 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 428.4 90 999999999 371.28 452.2 percent of total billed charges "RADIOLOGIC EXAMINATION, COMPLETE ACUTE ABDOMEN SERIES, INCLUDING 2 OR MORE VIEWS OF THE ABDOMEN (EG, SUPINE, ERECT, DECUBITUS), AND A SINGLE VIEW CHEST" 9513181_1 CDM 320 RC 74022 HCPCS outpatient 476 357 AETNA MCR ADV AETNA MCR ADV 371.28 78 999999999 371.28 452.2 percent of total billed charges "RADIOLOGIC EXAMINATION, COMPLETE ACUTE ABDOMEN SERIES, INCLUDING 2 OR MORE VIEWS OF THE ABDOMEN (EG, SUPINE, ERECT, DECUBITUS), AND A SINGLE VIEW CHEST" 9513181_1 CDM 320 RC 74022 HCPCS outpatient 476 357 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 416.83 87.57 999999999 371.28 452.2 percent of total billed charges "RADIOLOGIC EXAMINATION, COMPLETE ACUTE ABDOMEN SERIES, INCLUDING 2 OR MORE VIEWS OF THE ABDOMEN (EG, SUPINE, ERECT, DECUBITUS), AND A SINGLE VIEW CHEST" 9513181_1 CDM 320 RC 74022 HCPCS outpatient 476 357 COORDINATED CARE MCAID COORDINATED CARE MCAID 404.93 85.07 999999999 371.28 452.2 percent of total billed charges "RADIOLOGIC EXAMINATION, COMPLETE ACUTE ABDOMEN SERIES, INCLUDING 2 OR MORE VIEWS OF THE ABDOMEN (EG, SUPINE, ERECT, DECUBITUS), AND A SINGLE VIEW CHEST" 9513181_1 CDM 320 RC 74022 HCPCS outpatient 476 357 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 404.93 85.07 999999999 371.28 452.2 percent of total billed charges "RADIOLOGIC EXAMINATION, COMPLETE ACUTE ABDOMEN SERIES, INCLUDING 2 OR MORE VIEWS OF THE ABDOMEN (EG, SUPINE, ERECT, DECUBITUS), AND A SINGLE VIEW CHEST" 9513181_1 CDM 320 RC 74022 HCPCS outpatient 476 357 MOLINA MCAID MOLINA MCAID 396.98 83.4 999999999 371.28 452.2 percent of total billed charges "RADIOLOGIC EXAMINATION, COMPLETE ACUTE ABDOMEN SERIES, INCLUDING 2 OR MORE VIEWS OF THE ABDOMEN (EG, SUPINE, ERECT, DECUBITUS), AND A SINGLE VIEW CHEST" 9513181_1 CDM 320 RC 74022 HCPCS outpatient 476 357 MOLINA MCR ADV MOLINA MCR ADV 423.64 89 999999999 371.28 452.2 percent of total billed charges "RADIOLOGIC EXAMINATION, COMPLETE ACUTE ABDOMEN SERIES, INCLUDING 2 OR MORE VIEWS OF THE ABDOMEN (EG, SUPINE, ERECT, DECUBITUS), AND A SINGLE VIEW CHEST" 9513181_1 CDM 320 RC 74022 HCPCS outpatient 476 357 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 423.64 89 999999999 371.28 452.2 percent of total billed charges "RADIOLOGIC EXAMINATION, COMPLETE ACUTE ABDOMEN SERIES, INCLUDING 2 OR MORE VIEWS OF THE ABDOMEN (EG, SUPINE, ERECT, DECUBITUS), AND A SINGLE VIEW CHEST" 9513181_1 CDM 320 RC 74022 HCPCS outpatient 476 357 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 423.64 89 999999999 371.28 452.2 percent of total billed charges "RADIOLOGIC EXAMINATION, COMPLETE ACUTE ABDOMEN SERIES, INCLUDING 2 OR MORE VIEWS OF THE ABDOMEN (EG, SUPINE, ERECT, DECUBITUS), AND A SINGLE VIEW CHEST" 9513181_1 CDM 320 RC 74022 HCPCS outpatient 476 357 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 428.4 90 999999999 371.28 452.2 percent of total billed charges "RADIOLOGIC EXAMINATION, COMPLETE ACUTE ABDOMEN SERIES, INCLUDING 2 OR MORE VIEWS OF THE ABDOMEN (EG, SUPINE, ERECT, DECUBITUS), AND A SINGLE VIEW CHEST" 9513181_1 CDM 320 RC 74022 HCPCS outpatient 476 357 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 452.2 95 999999999 371.28 452.2 percent of total billed charges "RADIOLOGIC EXAMINATION, COMPLETE ACUTE ABDOMEN SERIES, INCLUDING 2 OR MORE VIEWS OF THE ABDOMEN (EG, SUPINE, ERECT, DECUBITUS), AND A SINGLE VIEW CHEST" 9513181_1 CDM 320 RC 74022 HCPCS outpatient 476 357 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 452.2 95 999999999 371.28 452.2 percent of total billed charges "RADIOLOGIC EXAMINATION, COMPLETE ACUTE ABDOMEN SERIES, INCLUDING 2 OR MORE VIEWS OF THE ABDOMEN (EG, SUPINE, ERECT, DECUBITUS), AND A SINGLE VIEW CHEST" 9513181_1 CDM 320 RC 74022 HCPCS outpatient 476 357 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 423.64 89 999999999 371.28 452.2 percent of total billed charges "RADIOLOGIC EXAMINATION, COMPLETE ACUTE ABDOMEN SERIES, INCLUDING 2 OR MORE VIEWS OF THE ABDOMEN (EG, SUPINE, ERECT, DECUBITUS), AND A SINGLE VIEW CHEST" 9513181_1 CDM 320 RC 74022 HCPCS outpatient 476 357 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 418.88 88 999999999 371.28 452.2 percent of total billed charges "RADIOLOGIC EXAMINATION, COMPLETE ACUTE ABDOMEN SERIES, INCLUDING 2 OR MORE VIEWS OF THE ABDOMEN (EG, SUPINE, ERECT, DECUBITUS), AND A SINGLE VIEW CHEST" 9513181_1 CDM 320 RC 74022 HCPCS outpatient 476 357 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 423.64 89 999999999 371.28 452.2 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL" 9513184_1 CDM 352 RC 74150 HCPCS outpatient 1605 1203.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1444.5 90 999999999 1251.9 1524.75 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL" 9513184_1 CDM 352 RC 74150 HCPCS outpatient 1605 1203.75 AETNA MCR ADV AETNA MCR ADV 1251.9 78 999999999 1251.9 1524.75 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL" 9513184_1 CDM 352 RC 74150 HCPCS outpatient 1605 1203.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1405.5 87.57 999999999 1251.9 1524.75 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL" 9513184_1 CDM 352 RC 74150 HCPCS outpatient 1605 1203.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 1365.37 85.07 999999999 1251.9 1524.75 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL" 9513184_1 CDM 352 RC 74150 HCPCS outpatient 1605 1203.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1365.37 85.07 999999999 1251.9 1524.75 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL" 9513184_1 CDM 352 RC 74150 HCPCS outpatient 1605 1203.75 MOLINA MCAID MOLINA MCAID 1338.57 83.4 999999999 1251.9 1524.75 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL" 9513184_1 CDM 352 RC 74150 HCPCS outpatient 1605 1203.75 MOLINA MCR ADV MOLINA MCR ADV 1428.45 89 999999999 1251.9 1524.75 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL" 9513184_1 CDM 352 RC 74150 HCPCS outpatient 1605 1203.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1428.45 89 999999999 1251.9 1524.75 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL" 9513184_1 CDM 352 RC 74150 HCPCS outpatient 1605 1203.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1428.45 89 999999999 1251.9 1524.75 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL" 9513184_1 CDM 352 RC 74150 HCPCS outpatient 1605 1203.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1444.5 90 999999999 1251.9 1524.75 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL" 9513184_1 CDM 352 RC 74150 HCPCS outpatient 1605 1203.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1524.75 95 999999999 1251.9 1524.75 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL" 9513184_1 CDM 352 RC 74150 HCPCS outpatient 1605 1203.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1524.75 95 999999999 1251.9 1524.75 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL" 9513184_1 CDM 352 RC 74150 HCPCS outpatient 1605 1203.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1428.45 89 999999999 1251.9 1524.75 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL" 9513184_1 CDM 352 RC 74150 HCPCS outpatient 1605 1203.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1412.4 88 999999999 1251.9 1524.75 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL" 9513184_1 CDM 352 RC 74150 HCPCS outpatient 1605 1203.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1428.45 89 999999999 1251.9 1524.75 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITH CONTRAST MATERIAL(S)" 9513188_1 CDM 352 RC 74160 HCPCS outpatient 2312 1734 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 2080.8 90 999999999 1803.36 2196.4 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITH CONTRAST MATERIAL(S)" 9513188_1 CDM 352 RC 74160 HCPCS outpatient 2312 1734 AETNA MCR ADV AETNA MCR ADV 1803.36 78 999999999 1803.36 2196.4 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITH CONTRAST MATERIAL(S)" 9513188_1 CDM 352 RC 74160 HCPCS outpatient 2312 1734 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 2024.62 87.57 999999999 1803.36 2196.4 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITH CONTRAST MATERIAL(S)" 9513188_1 CDM 352 RC 74160 HCPCS outpatient 2312 1734 COORDINATED CARE MCAID COORDINATED CARE MCAID 1966.82 85.07 999999999 1803.36 2196.4 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITH CONTRAST MATERIAL(S)" 9513188_1 CDM 352 RC 74160 HCPCS outpatient 2312 1734 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1966.82 85.07 999999999 1803.36 2196.4 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITH CONTRAST MATERIAL(S)" 9513188_1 CDM 352 RC 74160 HCPCS outpatient 2312 1734 MOLINA MCAID MOLINA MCAID 1928.21 83.4 999999999 1803.36 2196.4 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITH CONTRAST MATERIAL(S)" 9513188_1 CDM 352 RC 74160 HCPCS outpatient 2312 1734 MOLINA MCR ADV MOLINA MCR ADV 2057.68 89 999999999 1803.36 2196.4 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITH CONTRAST MATERIAL(S)" 9513188_1 CDM 352 RC 74160 HCPCS outpatient 2312 1734 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 2057.68 89 999999999 1803.36 2196.4 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITH CONTRAST MATERIAL(S)" 9513188_1 CDM 352 RC 74160 HCPCS outpatient 2312 1734 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 2057.68 89 999999999 1803.36 2196.4 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITH CONTRAST MATERIAL(S)" 9513188_1 CDM 352 RC 74160 HCPCS outpatient 2312 1734 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 2080.8 90 999999999 1803.36 2196.4 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITH CONTRAST MATERIAL(S)" 9513188_1 CDM 352 RC 74160 HCPCS outpatient 2312 1734 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 2196.4 95 999999999 1803.36 2196.4 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITH CONTRAST MATERIAL(S)" 9513188_1 CDM 352 RC 74160 HCPCS outpatient 2312 1734 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 2196.4 95 999999999 1803.36 2196.4 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITH CONTRAST MATERIAL(S)" 9513188_1 CDM 352 RC 74160 HCPCS outpatient 2312 1734 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 2057.68 89 999999999 1803.36 2196.4 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITH CONTRAST MATERIAL(S)" 9513188_1 CDM 352 RC 74160 HCPCS outpatient 2312 1734 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 2034.56 88 999999999 1803.36 2196.4 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITH CONTRAST MATERIAL(S)" 9513188_1 CDM 352 RC 74160 HCPCS outpatient 2312 1734 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 2057.68 89 999999999 1803.36 2196.4 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513191_1 CDM 352 RC 74170 HCPCS outpatient 2645 1983.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 2380.5 90 999999999 2063.1 2512.75 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513191_1 CDM 352 RC 74170 HCPCS outpatient 2645 1983.75 AETNA MCR ADV AETNA MCR ADV 2063.1 78 999999999 2063.1 2512.75 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513191_1 CDM 352 RC 74170 HCPCS outpatient 2645 1983.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 2316.23 87.57 999999999 2063.1 2512.75 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513191_1 CDM 352 RC 74170 HCPCS outpatient 2645 1983.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 2250.1 85.07 999999999 2063.1 2512.75 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513191_1 CDM 352 RC 74170 HCPCS outpatient 2645 1983.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 2250.1 85.07 999999999 2063.1 2512.75 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513191_1 CDM 352 RC 74170 HCPCS outpatient 2645 1983.75 MOLINA MCAID MOLINA MCAID 2205.93 83.4 999999999 2063.1 2512.75 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513191_1 CDM 352 RC 74170 HCPCS outpatient 2645 1983.75 MOLINA MCR ADV MOLINA MCR ADV 2354.05 89 999999999 2063.1 2512.75 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513191_1 CDM 352 RC 74170 HCPCS outpatient 2645 1983.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 2354.05 89 999999999 2063.1 2512.75 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513191_1 CDM 352 RC 74170 HCPCS outpatient 2645 1983.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 2354.05 89 999999999 2063.1 2512.75 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513191_1 CDM 352 RC 74170 HCPCS outpatient 2645 1983.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 2380.5 90 999999999 2063.1 2512.75 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513191_1 CDM 352 RC 74170 HCPCS outpatient 2645 1983.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 2512.75 95 999999999 2063.1 2512.75 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513191_1 CDM 352 RC 74170 HCPCS outpatient 2645 1983.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 2512.75 95 999999999 2063.1 2512.75 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513191_1 CDM 352 RC 74170 HCPCS outpatient 2645 1983.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 2354.05 89 999999999 2063.1 2512.75 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513191_1 CDM 352 RC 74170 HCPCS outpatient 2645 1983.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 2327.6 88 999999999 2063.1 2512.75 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS" 9513191_1 CDM 352 RC 74170 HCPCS outpatient 2645 1983.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 2354.05 89 999999999 2063.1 2512.75 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITHOUT CONTRAST MATERIAL(S)" 9513197_1 CDM 610 RC 74181 HCPCS outpatient 2193 1644.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1973.7 90 999999999 1710.54 2083.35 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITHOUT CONTRAST MATERIAL(S)" 9513197_1 CDM 610 RC 74181 HCPCS outpatient 2193 1644.75 AETNA MCR ADV AETNA MCR ADV 1710.54 78 999999999 1710.54 2083.35 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITHOUT CONTRAST MATERIAL(S)" 9513197_1 CDM 610 RC 74181 HCPCS outpatient 2193 1644.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1920.41 87.57 999999999 1710.54 2083.35 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITHOUT CONTRAST MATERIAL(S)" 9513197_1 CDM 610 RC 74181 HCPCS outpatient 2193 1644.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 1865.59 85.07 999999999 1710.54 2083.35 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITHOUT CONTRAST MATERIAL(S)" 9513197_1 CDM 610 RC 74181 HCPCS outpatient 2193 1644.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1865.59 85.07 999999999 1710.54 2083.35 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITHOUT CONTRAST MATERIAL(S)" 9513197_1 CDM 610 RC 74181 HCPCS outpatient 2193 1644.75 MOLINA MCAID MOLINA MCAID 1828.96 83.4 999999999 1710.54 2083.35 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITHOUT CONTRAST MATERIAL(S)" 9513197_1 CDM 610 RC 74181 HCPCS outpatient 2193 1644.75 MOLINA MCR ADV MOLINA MCR ADV 1951.77 89 999999999 1710.54 2083.35 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITHOUT CONTRAST MATERIAL(S)" 9513197_1 CDM 610 RC 74181 HCPCS outpatient 2193 1644.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1951.77 89 999999999 1710.54 2083.35 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITHOUT CONTRAST MATERIAL(S)" 9513197_1 CDM 610 RC 74181 HCPCS outpatient 2193 1644.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1951.77 89 999999999 1710.54 2083.35 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITHOUT CONTRAST MATERIAL(S)" 9513197_1 CDM 610 RC 74181 HCPCS outpatient 2193 1644.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1973.7 90 999999999 1710.54 2083.35 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITHOUT CONTRAST MATERIAL(S)" 9513197_1 CDM 610 RC 74181 HCPCS outpatient 2193 1644.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 2083.35 95 999999999 1710.54 2083.35 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITHOUT CONTRAST MATERIAL(S)" 9513197_1 CDM 610 RC 74181 HCPCS outpatient 2193 1644.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 2083.35 95 999999999 1710.54 2083.35 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITHOUT CONTRAST MATERIAL(S)" 9513197_1 CDM 610 RC 74181 HCPCS outpatient 2193 1644.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1951.77 89 999999999 1710.54 2083.35 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITHOUT CONTRAST MATERIAL(S)" 9513197_1 CDM 610 RC 74181 HCPCS outpatient 2193 1644.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1929.84 88 999999999 1710.54 2083.35 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITHOUT CONTRAST MATERIAL(S)" 9513197_1 CDM 610 RC 74181 HCPCS outpatient 2193 1644.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1951.77 89 999999999 1710.54 2083.35 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITH CONTRAST MATERIAL(S)" 9513200_1 CDM 610 RC 74182 HCPCS outpatient 2787 2090.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 2508.3 90 999999999 2173.86 2647.65 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITH CONTRAST MATERIAL(S)" 9513200_1 CDM 610 RC 74182 HCPCS outpatient 2787 2090.25 AETNA MCR ADV AETNA MCR ADV 2173.86 78 999999999 2173.86 2647.65 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITH CONTRAST MATERIAL(S)" 9513200_1 CDM 610 RC 74182 HCPCS outpatient 2787 2090.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 2440.58 87.57 999999999 2173.86 2647.65 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITH CONTRAST MATERIAL(S)" 9513200_1 CDM 610 RC 74182 HCPCS outpatient 2787 2090.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 2370.9 85.07 999999999 2173.86 2647.65 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITH CONTRAST MATERIAL(S)" 9513200_1 CDM 610 RC 74182 HCPCS outpatient 2787 2090.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 2370.9 85.07 999999999 2173.86 2647.65 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITH CONTRAST MATERIAL(S)" 9513200_1 CDM 610 RC 74182 HCPCS outpatient 2787 2090.25 MOLINA MCAID MOLINA MCAID 2324.36 83.4 999999999 2173.86 2647.65 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITH CONTRAST MATERIAL(S)" 9513200_1 CDM 610 RC 74182 HCPCS outpatient 2787 2090.25 MOLINA MCR ADV MOLINA MCR ADV 2480.43 89 999999999 2173.86 2647.65 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITH CONTRAST MATERIAL(S)" 9513200_1 CDM 610 RC 74182 HCPCS outpatient 2787 2090.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 2480.43 89 999999999 2173.86 2647.65 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITH CONTRAST MATERIAL(S)" 9513200_1 CDM 610 RC 74182 HCPCS outpatient 2787 2090.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 2480.43 89 999999999 2173.86 2647.65 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITH CONTRAST MATERIAL(S)" 9513200_1 CDM 610 RC 74182 HCPCS outpatient 2787 2090.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 2508.3 90 999999999 2173.86 2647.65 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITH CONTRAST MATERIAL(S)" 9513200_1 CDM 610 RC 74182 HCPCS outpatient 2787 2090.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 2647.65 95 999999999 2173.86 2647.65 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITH CONTRAST MATERIAL(S)" 9513200_1 CDM 610 RC 74182 HCPCS outpatient 2787 2090.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 2647.65 95 999999999 2173.86 2647.65 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITH CONTRAST MATERIAL(S)" 9513200_1 CDM 610 RC 74182 HCPCS outpatient 2787 2090.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 2480.43 89 999999999 2173.86 2647.65 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITH CONTRAST MATERIAL(S)" 9513200_1 CDM 610 RC 74182 HCPCS outpatient 2787 2090.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 2452.56 88 999999999 2173.86 2647.65 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITH CONTRAST MATERIAL(S)" 9513200_1 CDM 610 RC 74182 HCPCS outpatient 2787 2090.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 2480.43 89 999999999 2173.86 2647.65 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY WITH CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9513203_1 CDM 610 RC 74183 HCPCS outpatient 3819 2864.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 3437.1 90 999999999 2978.82 3628.05 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY WITH CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9513203_1 CDM 610 RC 74183 HCPCS outpatient 3819 2864.25 AETNA MCR ADV AETNA MCR ADV 2978.82 78 999999999 2978.82 3628.05 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY WITH CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9513203_1 CDM 610 RC 74183 HCPCS outpatient 3819 2864.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 3344.3 87.57 999999999 2978.82 3628.05 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY WITH CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9513203_1 CDM 610 RC 74183 HCPCS outpatient 3819 2864.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 3248.82 85.07 999999999 2978.82 3628.05 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY WITH CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9513203_1 CDM 610 RC 74183 HCPCS outpatient 3819 2864.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 3248.82 85.07 999999999 2978.82 3628.05 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY WITH CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9513203_1 CDM 610 RC 74183 HCPCS outpatient 3819 2864.25 MOLINA MCAID MOLINA MCAID 3185.05 83.4 999999999 2978.82 3628.05 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY WITH CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9513203_1 CDM 610 RC 74183 HCPCS outpatient 3819 2864.25 MOLINA MCR ADV MOLINA MCR ADV 3398.91 89 999999999 2978.82 3628.05 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY WITH CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9513203_1 CDM 610 RC 74183 HCPCS outpatient 3819 2864.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 3398.91 89 999999999 2978.82 3628.05 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY WITH CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9513203_1 CDM 610 RC 74183 HCPCS outpatient 3819 2864.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 3398.91 89 999999999 2978.82 3628.05 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY WITH CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9513203_1 CDM 610 RC 74183 HCPCS outpatient 3819 2864.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 3437.1 90 999999999 2978.82 3628.05 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY WITH CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9513203_1 CDM 610 RC 74183 HCPCS outpatient 3819 2864.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 3628.05 95 999999999 2978.82 3628.05 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY WITH CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9513203_1 CDM 610 RC 74183 HCPCS outpatient 3819 2864.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 3628.05 95 999999999 2978.82 3628.05 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY WITH CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9513203_1 CDM 610 RC 74183 HCPCS outpatient 3819 2864.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 3398.91 89 999999999 2978.82 3628.05 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY WITH CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9513203_1 CDM 610 RC 74183 HCPCS outpatient 3819 2864.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 3360.72 88 999999999 2978.82 3628.05 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY WITH CONTRAST MATERIAL(S) AND FURTHER SEQUENCES" 9513203_1 CDM 610 RC 74183 HCPCS outpatient 3819 2864.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 3398.91 89 999999999 2978.82 3628.05 percent of total billed charges "ULTRASOUND, SOFT TISSUES OF HEAD AND NECK (EG, THYROID, PARATHYROID, PAROTID), REAL TIME WITH IMAGE DOCUMENTATION" 9513518_1 CDM 402 RC 76536 HCPCS outpatient 750 562.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 675 90 999999999 585 712.5 percent of total billed charges "ULTRASOUND, SOFT TISSUES OF HEAD AND NECK (EG, THYROID, PARATHYROID, PAROTID), REAL TIME WITH IMAGE DOCUMENTATION" 9513518_1 CDM 402 RC 76536 HCPCS outpatient 750 562.5 AETNA MCR ADV AETNA MCR ADV 585 78 999999999 585 712.5 percent of total billed charges "ULTRASOUND, SOFT TISSUES OF HEAD AND NECK (EG, THYROID, PARATHYROID, PAROTID), REAL TIME WITH IMAGE DOCUMENTATION" 9513518_1 CDM 402 RC 76536 HCPCS outpatient 750 562.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 656.78 87.57 999999999 585 712.5 percent of total billed charges "ULTRASOUND, SOFT TISSUES OF HEAD AND NECK (EG, THYROID, PARATHYROID, PAROTID), REAL TIME WITH IMAGE DOCUMENTATION" 9513518_1 CDM 402 RC 76536 HCPCS outpatient 750 562.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 638.03 85.07 999999999 585 712.5 percent of total billed charges "ULTRASOUND, SOFT TISSUES OF HEAD AND NECK (EG, THYROID, PARATHYROID, PAROTID), REAL TIME WITH IMAGE DOCUMENTATION" 9513518_1 CDM 402 RC 76536 HCPCS outpatient 750 562.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 638.03 85.07 999999999 585 712.5 percent of total billed charges "ULTRASOUND, SOFT TISSUES OF HEAD AND NECK (EG, THYROID, PARATHYROID, PAROTID), REAL TIME WITH IMAGE DOCUMENTATION" 9513518_1 CDM 402 RC 76536 HCPCS outpatient 750 562.5 MOLINA MCAID MOLINA MCAID 625.5 83.4 999999999 585 712.5 percent of total billed charges "ULTRASOUND, SOFT TISSUES OF HEAD AND NECK (EG, THYROID, PARATHYROID, PAROTID), REAL TIME WITH IMAGE DOCUMENTATION" 9513518_1 CDM 402 RC 76536 HCPCS outpatient 750 562.5 MOLINA MCR ADV MOLINA MCR ADV 667.5 89 999999999 585 712.5 percent of total billed charges "ULTRASOUND, SOFT TISSUES OF HEAD AND NECK (EG, THYROID, PARATHYROID, PAROTID), REAL TIME WITH IMAGE DOCUMENTATION" 9513518_1 CDM 402 RC 76536 HCPCS outpatient 750 562.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 667.5 89 999999999 585 712.5 percent of total billed charges "ULTRASOUND, SOFT TISSUES OF HEAD AND NECK (EG, THYROID, PARATHYROID, PAROTID), REAL TIME WITH IMAGE DOCUMENTATION" 9513518_1 CDM 402 RC 76536 HCPCS outpatient 750 562.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 667.5 89 999999999 585 712.5 percent of total billed charges "ULTRASOUND, SOFT TISSUES OF HEAD AND NECK (EG, THYROID, PARATHYROID, PAROTID), REAL TIME WITH IMAGE DOCUMENTATION" 9513518_1 CDM 402 RC 76536 HCPCS outpatient 750 562.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 675 90 999999999 585 712.5 percent of total billed charges "ULTRASOUND, SOFT TISSUES OF HEAD AND NECK (EG, THYROID, PARATHYROID, PAROTID), REAL TIME WITH IMAGE DOCUMENTATION" 9513518_1 CDM 402 RC 76536 HCPCS outpatient 750 562.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 712.5 95 999999999 585 712.5 percent of total billed charges "ULTRASOUND, SOFT TISSUES OF HEAD AND NECK (EG, THYROID, PARATHYROID, PAROTID), REAL TIME WITH IMAGE DOCUMENTATION" 9513518_1 CDM 402 RC 76536 HCPCS outpatient 750 562.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 712.5 95 999999999 585 712.5 percent of total billed charges "ULTRASOUND, SOFT TISSUES OF HEAD AND NECK (EG, THYROID, PARATHYROID, PAROTID), REAL TIME WITH IMAGE DOCUMENTATION" 9513518_1 CDM 402 RC 76536 HCPCS outpatient 750 562.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 667.5 89 999999999 585 712.5 percent of total billed charges "ULTRASOUND, SOFT TISSUES OF HEAD AND NECK (EG, THYROID, PARATHYROID, PAROTID), REAL TIME WITH IMAGE DOCUMENTATION" 9513518_1 CDM 402 RC 76536 HCPCS outpatient 750 562.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 660 88 999999999 585 712.5 percent of total billed charges "ULTRASOUND, SOFT TISSUES OF HEAD AND NECK (EG, THYROID, PARATHYROID, PAROTID), REAL TIME WITH IMAGE DOCUMENTATION" 9513518_1 CDM 402 RC 76536 HCPCS outpatient 750 562.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 667.5 89 999999999 585 712.5 percent of total billed charges "ULTRASOUND, ABDOMINAL, REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513527_1 CDM 402 RC 76700 HCPCS outpatient 916 687 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 824.4 90 999999999 714.48 870.2 percent of total billed charges "ULTRASOUND, ABDOMINAL, REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513527_1 CDM 402 RC 76700 HCPCS outpatient 916 687 AETNA MCR ADV AETNA MCR ADV 714.48 78 999999999 714.48 870.2 percent of total billed charges "ULTRASOUND, ABDOMINAL, REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513527_1 CDM 402 RC 76700 HCPCS outpatient 916 687 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 802.14 87.57 999999999 714.48 870.2 percent of total billed charges "ULTRASOUND, ABDOMINAL, REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513527_1 CDM 402 RC 76700 HCPCS outpatient 916 687 COORDINATED CARE MCAID COORDINATED CARE MCAID 779.24 85.07 999999999 714.48 870.2 percent of total billed charges "ULTRASOUND, ABDOMINAL, REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513527_1 CDM 402 RC 76700 HCPCS outpatient 916 687 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 779.24 85.07 999999999 714.48 870.2 percent of total billed charges "ULTRASOUND, ABDOMINAL, REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513527_1 CDM 402 RC 76700 HCPCS outpatient 916 687 MOLINA MCAID MOLINA MCAID 763.94 83.4 999999999 714.48 870.2 percent of total billed charges "ULTRASOUND, ABDOMINAL, REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513527_1 CDM 402 RC 76700 HCPCS outpatient 916 687 MOLINA MCR ADV MOLINA MCR ADV 815.24 89 999999999 714.48 870.2 percent of total billed charges "ULTRASOUND, ABDOMINAL, REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513527_1 CDM 402 RC 76700 HCPCS outpatient 916 687 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 815.24 89 999999999 714.48 870.2 percent of total billed charges "ULTRASOUND, ABDOMINAL, REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513527_1 CDM 402 RC 76700 HCPCS outpatient 916 687 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 815.24 89 999999999 714.48 870.2 percent of total billed charges "ULTRASOUND, ABDOMINAL, REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513527_1 CDM 402 RC 76700 HCPCS outpatient 916 687 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 824.4 90 999999999 714.48 870.2 percent of total billed charges "ULTRASOUND, ABDOMINAL, REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513527_1 CDM 402 RC 76700 HCPCS outpatient 916 687 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 870.2 95 999999999 714.48 870.2 percent of total billed charges "ULTRASOUND, ABDOMINAL, REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513527_1 CDM 402 RC 76700 HCPCS outpatient 916 687 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 870.2 95 999999999 714.48 870.2 percent of total billed charges "ULTRASOUND, ABDOMINAL, REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513527_1 CDM 402 RC 76700 HCPCS outpatient 916 687 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 815.24 89 999999999 714.48 870.2 percent of total billed charges "ULTRASOUND, ABDOMINAL, REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513527_1 CDM 402 RC 76700 HCPCS outpatient 916 687 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 806.08 88 999999999 714.48 870.2 percent of total billed charges "ULTRASOUND, ABDOMINAL, REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513527_1 CDM 402 RC 76700 HCPCS outpatient 916 687 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 815.24 89 999999999 714.48 870.2 percent of total billed charges "ULTRASOUND, ABDOMINAL, REAL TIME WITH IMAGE DOCUMENTATION; LIMITED (EG, SINGLE ORGAN, QUADRANT, FOLLOW-UP)" 9513530_1 CDM 402 RC 76705 HCPCS outpatient 788 591 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 709.2 90 999999999 614.64 748.6 percent of total billed charges "ULTRASOUND, ABDOMINAL, REAL TIME WITH IMAGE DOCUMENTATION; LIMITED (EG, SINGLE ORGAN, QUADRANT, FOLLOW-UP)" 9513530_1 CDM 402 RC 76705 HCPCS outpatient 788 591 AETNA MCR ADV AETNA MCR ADV 614.64 78 999999999 614.64 748.6 percent of total billed charges "ULTRASOUND, ABDOMINAL, REAL TIME WITH IMAGE DOCUMENTATION; LIMITED (EG, SINGLE ORGAN, QUADRANT, FOLLOW-UP)" 9513530_1 CDM 402 RC 76705 HCPCS outpatient 788 591 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 690.05 87.57 999999999 614.64 748.6 percent of total billed charges "ULTRASOUND, ABDOMINAL, REAL TIME WITH IMAGE DOCUMENTATION; LIMITED (EG, SINGLE ORGAN, QUADRANT, FOLLOW-UP)" 9513530_1 CDM 402 RC 76705 HCPCS outpatient 788 591 COORDINATED CARE MCAID COORDINATED CARE MCAID 670.35 85.07 999999999 614.64 748.6 percent of total billed charges "ULTRASOUND, ABDOMINAL, REAL TIME WITH IMAGE DOCUMENTATION; LIMITED (EG, SINGLE ORGAN, QUADRANT, FOLLOW-UP)" 9513530_1 CDM 402 RC 76705 HCPCS outpatient 788 591 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 670.35 85.07 999999999 614.64 748.6 percent of total billed charges "ULTRASOUND, ABDOMINAL, REAL TIME WITH IMAGE DOCUMENTATION; LIMITED (EG, SINGLE ORGAN, QUADRANT, FOLLOW-UP)" 9513530_1 CDM 402 RC 76705 HCPCS outpatient 788 591 MOLINA MCAID MOLINA MCAID 657.19 83.4 999999999 614.64 748.6 percent of total billed charges "ULTRASOUND, ABDOMINAL, REAL TIME WITH IMAGE DOCUMENTATION; LIMITED (EG, SINGLE ORGAN, QUADRANT, FOLLOW-UP)" 9513530_1 CDM 402 RC 76705 HCPCS outpatient 788 591 MOLINA MCR ADV MOLINA MCR ADV 701.32 89 999999999 614.64 748.6 percent of total billed charges "ULTRASOUND, ABDOMINAL, REAL TIME WITH IMAGE DOCUMENTATION; LIMITED (EG, SINGLE ORGAN, QUADRANT, FOLLOW-UP)" 9513530_1 CDM 402 RC 76705 HCPCS outpatient 788 591 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 701.32 89 999999999 614.64 748.6 percent of total billed charges "ULTRASOUND, ABDOMINAL, REAL TIME WITH IMAGE DOCUMENTATION; LIMITED (EG, SINGLE ORGAN, QUADRANT, FOLLOW-UP)" 9513530_1 CDM 402 RC 76705 HCPCS outpatient 788 591 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 701.32 89 999999999 614.64 748.6 percent of total billed charges "ULTRASOUND, ABDOMINAL, REAL TIME WITH IMAGE DOCUMENTATION; LIMITED (EG, SINGLE ORGAN, QUADRANT, FOLLOW-UP)" 9513530_1 CDM 402 RC 76705 HCPCS outpatient 788 591 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 709.2 90 999999999 614.64 748.6 percent of total billed charges "ULTRASOUND, ABDOMINAL, REAL TIME WITH IMAGE DOCUMENTATION; LIMITED (EG, SINGLE ORGAN, QUADRANT, FOLLOW-UP)" 9513530_1 CDM 402 RC 76705 HCPCS outpatient 788 591 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 748.6 95 999999999 614.64 748.6 percent of total billed charges "ULTRASOUND, ABDOMINAL, REAL TIME WITH IMAGE DOCUMENTATION; LIMITED (EG, SINGLE ORGAN, QUADRANT, FOLLOW-UP)" 9513530_1 CDM 402 RC 76705 HCPCS outpatient 788 591 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 748.6 95 999999999 614.64 748.6 percent of total billed charges "ULTRASOUND, ABDOMINAL, REAL TIME WITH IMAGE DOCUMENTATION; LIMITED (EG, SINGLE ORGAN, QUADRANT, FOLLOW-UP)" 9513530_1 CDM 402 RC 76705 HCPCS outpatient 788 591 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 701.32 89 999999999 614.64 748.6 percent of total billed charges "ULTRASOUND, ABDOMINAL, REAL TIME WITH IMAGE DOCUMENTATION; LIMITED (EG, SINGLE ORGAN, QUADRANT, FOLLOW-UP)" 9513530_1 CDM 402 RC 76705 HCPCS outpatient 788 591 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 693.44 88 999999999 614.64 748.6 percent of total billed charges "ULTRASOUND, ABDOMINAL, REAL TIME WITH IMAGE DOCUMENTATION; LIMITED (EG, SINGLE ORGAN, QUADRANT, FOLLOW-UP)" 9513530_1 CDM 402 RC 76705 HCPCS outpatient 788 591 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 701.32 89 999999999 614.64 748.6 percent of total billed charges "ULTRASOUND, RETROPERITONEAL (EG, RENAL, AORTA, NODES), REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513533_1 CDM 402 RC 76770 HCPCS outpatient 895 671.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 805.5 90 999999999 698.1 850.25 percent of total billed charges "ULTRASOUND, RETROPERITONEAL (EG, RENAL, AORTA, NODES), REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513533_1 CDM 402 RC 76770 HCPCS outpatient 895 671.25 AETNA MCR ADV AETNA MCR ADV 698.1 78 999999999 698.1 850.25 percent of total billed charges "ULTRASOUND, RETROPERITONEAL (EG, RENAL, AORTA, NODES), REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513533_1 CDM 402 RC 76770 HCPCS outpatient 895 671.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 783.75 87.57 999999999 698.1 850.25 percent of total billed charges "ULTRASOUND, RETROPERITONEAL (EG, RENAL, AORTA, NODES), REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513533_1 CDM 402 RC 76770 HCPCS outpatient 895 671.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 761.38 85.07 999999999 698.1 850.25 percent of total billed charges "ULTRASOUND, RETROPERITONEAL (EG, RENAL, AORTA, NODES), REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513533_1 CDM 402 RC 76770 HCPCS outpatient 895 671.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 761.38 85.07 999999999 698.1 850.25 percent of total billed charges "ULTRASOUND, RETROPERITONEAL (EG, RENAL, AORTA, NODES), REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513533_1 CDM 402 RC 76770 HCPCS outpatient 895 671.25 MOLINA MCAID MOLINA MCAID 746.43 83.4 999999999 698.1 850.25 percent of total billed charges "ULTRASOUND, RETROPERITONEAL (EG, RENAL, AORTA, NODES), REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513533_1 CDM 402 RC 76770 HCPCS outpatient 895 671.25 MOLINA MCR ADV MOLINA MCR ADV 796.55 89 999999999 698.1 850.25 percent of total billed charges "ULTRASOUND, RETROPERITONEAL (EG, RENAL, AORTA, NODES), REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513533_1 CDM 402 RC 76770 HCPCS outpatient 895 671.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 796.55 89 999999999 698.1 850.25 percent of total billed charges "ULTRASOUND, RETROPERITONEAL (EG, RENAL, AORTA, NODES), REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513533_1 CDM 402 RC 76770 HCPCS outpatient 895 671.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 796.55 89 999999999 698.1 850.25 percent of total billed charges "ULTRASOUND, RETROPERITONEAL (EG, RENAL, AORTA, NODES), REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513533_1 CDM 402 RC 76770 HCPCS outpatient 895 671.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 805.5 90 999999999 698.1 850.25 percent of total billed charges "ULTRASOUND, RETROPERITONEAL (EG, RENAL, AORTA, NODES), REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513533_1 CDM 402 RC 76770 HCPCS outpatient 895 671.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 850.25 95 999999999 698.1 850.25 percent of total billed charges "ULTRASOUND, RETROPERITONEAL (EG, RENAL, AORTA, NODES), REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513533_1 CDM 402 RC 76770 HCPCS outpatient 895 671.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 850.25 95 999999999 698.1 850.25 percent of total billed charges "ULTRASOUND, RETROPERITONEAL (EG, RENAL, AORTA, NODES), REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513533_1 CDM 402 RC 76770 HCPCS outpatient 895 671.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 796.55 89 999999999 698.1 850.25 percent of total billed charges "ULTRASOUND, RETROPERITONEAL (EG, RENAL, AORTA, NODES), REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513533_1 CDM 402 RC 76770 HCPCS outpatient 895 671.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 787.6 88 999999999 698.1 850.25 percent of total billed charges "ULTRASOUND, RETROPERITONEAL (EG, RENAL, AORTA, NODES), REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513533_1 CDM 402 RC 76770 HCPCS outpatient 895 671.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 796.55 89 999999999 698.1 850.25 percent of total billed charges "ULTRASOUND, RETROPERITONEAL (EG, RENAL, AORTA, NODES), REAL TIME WITH IMAGE DOCUMENTATION; LIMITED" 9513536_1 CDM 402 RC 76775 HCPCS outpatient 703 527.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 632.7 90 999999999 548.34 667.85 percent of total billed charges "ULTRASOUND, RETROPERITONEAL (EG, RENAL, AORTA, NODES), REAL TIME WITH IMAGE DOCUMENTATION; LIMITED" 9513536_1 CDM 402 RC 76775 HCPCS outpatient 703 527.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 667.85 95 999999999 548.34 667.85 percent of total billed charges "ULTRASOUND, RETROPERITONEAL (EG, RENAL, AORTA, NODES), REAL TIME WITH IMAGE DOCUMENTATION; LIMITED" 9513536_1 CDM 402 RC 76775 HCPCS outpatient 703 527.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 667.85 95 999999999 548.34 667.85 percent of total billed charges "ULTRASOUND, RETROPERITONEAL (EG, RENAL, AORTA, NODES), REAL TIME WITH IMAGE DOCUMENTATION; LIMITED" 9513536_1 CDM 402 RC 76775 HCPCS outpatient 703 527.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 625.67 89 999999999 548.34 667.85 percent of total billed charges "ULTRASOUND, RETROPERITONEAL (EG, RENAL, AORTA, NODES), REAL TIME WITH IMAGE DOCUMENTATION; LIMITED" 9513536_1 CDM 402 RC 76775 HCPCS outpatient 703 527.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 618.64 88 999999999 548.34 667.85 percent of total billed charges "ULTRASOUND, RETROPERITONEAL (EG, RENAL, AORTA, NODES), REAL TIME WITH IMAGE DOCUMENTATION; LIMITED" 9513536_1 CDM 402 RC 76775 HCPCS outpatient 703 527.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 625.67 89 999999999 548.34 667.85 percent of total billed charges "ULTRASOUND, RETROPERITONEAL (EG, RENAL, AORTA, NODES), REAL TIME WITH IMAGE DOCUMENTATION; LIMITED" 9513536_1 CDM 402 RC 76775 HCPCS outpatient 703 527.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 632.7 90 999999999 548.34 667.85 percent of total billed charges "ULTRASOUND, RETROPERITONEAL (EG, RENAL, AORTA, NODES), REAL TIME WITH IMAGE DOCUMENTATION; LIMITED" 9513536_1 CDM 402 RC 76775 HCPCS outpatient 703 527.25 AETNA MCR ADV AETNA MCR ADV 548.34 78 999999999 548.34 667.85 percent of total billed charges "ULTRASOUND, RETROPERITONEAL (EG, RENAL, AORTA, NODES), REAL TIME WITH IMAGE DOCUMENTATION; LIMITED" 9513536_1 CDM 402 RC 76775 HCPCS outpatient 703 527.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 615.62 87.57 999999999 548.34 667.85 percent of total billed charges "ULTRASOUND, RETROPERITONEAL (EG, RENAL, AORTA, NODES), REAL TIME WITH IMAGE DOCUMENTATION; LIMITED" 9513536_1 CDM 402 RC 76775 HCPCS outpatient 703 527.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 598.04 85.07 999999999 548.34 667.85 percent of total billed charges "ULTRASOUND, RETROPERITONEAL (EG, RENAL, AORTA, NODES), REAL TIME WITH IMAGE DOCUMENTATION; LIMITED" 9513536_1 CDM 402 RC 76775 HCPCS outpatient 703 527.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 598.04 85.07 999999999 548.34 667.85 percent of total billed charges "ULTRASOUND, RETROPERITONEAL (EG, RENAL, AORTA, NODES), REAL TIME WITH IMAGE DOCUMENTATION; LIMITED" 9513536_1 CDM 402 RC 76775 HCPCS outpatient 703 527.25 MOLINA MCAID MOLINA MCAID 586.3 83.4 999999999 548.34 667.85 percent of total billed charges "ULTRASOUND, RETROPERITONEAL (EG, RENAL, AORTA, NODES), REAL TIME WITH IMAGE DOCUMENTATION; LIMITED" 9513536_1 CDM 402 RC 76775 HCPCS outpatient 703 527.25 MOLINA MCR ADV MOLINA MCR ADV 625.67 89 999999999 548.34 667.85 percent of total billed charges "ULTRASOUND, RETROPERITONEAL (EG, RENAL, AORTA, NODES), REAL TIME WITH IMAGE DOCUMENTATION; LIMITED" 9513536_1 CDM 402 RC 76775 HCPCS outpatient 703 527.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 625.67 89 999999999 548.34 667.85 percent of total billed charges "ULTRASOUND, RETROPERITONEAL (EG, RENAL, AORTA, NODES), REAL TIME WITH IMAGE DOCUMENTATION; LIMITED" 9513536_1 CDM 402 RC 76775 HCPCS outpatient 703 527.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 625.67 89 999999999 548.34 667.85 percent of total billed charges "ULTRASOUND, TRANSPLANTED KIDNEY, REAL TIME AND DUPLEX DOPPLER WITH IMAGE DOCUMENTATION" 9513539_1 CDM 402 RC 76776 HCPCS outpatient 861 645.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 774.9 90 999999999 671.58 817.95 percent of total billed charges "ULTRASOUND, TRANSPLANTED KIDNEY, REAL TIME AND DUPLEX DOPPLER WITH IMAGE DOCUMENTATION" 9513539_1 CDM 402 RC 76776 HCPCS outpatient 861 645.75 AETNA MCR ADV AETNA MCR ADV 671.58 78 999999999 671.58 817.95 percent of total billed charges "ULTRASOUND, TRANSPLANTED KIDNEY, REAL TIME AND DUPLEX DOPPLER WITH IMAGE DOCUMENTATION" 9513539_1 CDM 402 RC 76776 HCPCS outpatient 861 645.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 753.98 87.57 999999999 671.58 817.95 percent of total billed charges "ULTRASOUND, TRANSPLANTED KIDNEY, REAL TIME AND DUPLEX DOPPLER WITH IMAGE DOCUMENTATION" 9513539_1 CDM 402 RC 76776 HCPCS outpatient 861 645.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 732.45 85.07 999999999 671.58 817.95 percent of total billed charges "ULTRASOUND, TRANSPLANTED KIDNEY, REAL TIME AND DUPLEX DOPPLER WITH IMAGE DOCUMENTATION" 9513539_1 CDM 402 RC 76776 HCPCS outpatient 861 645.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 732.45 85.07 999999999 671.58 817.95 percent of total billed charges "ULTRASOUND, TRANSPLANTED KIDNEY, REAL TIME AND DUPLEX DOPPLER WITH IMAGE DOCUMENTATION" 9513539_1 CDM 402 RC 76776 HCPCS outpatient 861 645.75 MOLINA MCAID MOLINA MCAID 718.07 83.4 999999999 671.58 817.95 percent of total billed charges "ULTRASOUND, TRANSPLANTED KIDNEY, REAL TIME AND DUPLEX DOPPLER WITH IMAGE DOCUMENTATION" 9513539_1 CDM 402 RC 76776 HCPCS outpatient 861 645.75 MOLINA MCR ADV MOLINA MCR ADV 766.29 89 999999999 671.58 817.95 percent of total billed charges "ULTRASOUND, TRANSPLANTED KIDNEY, REAL TIME AND DUPLEX DOPPLER WITH IMAGE DOCUMENTATION" 9513539_1 CDM 402 RC 76776 HCPCS outpatient 861 645.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 766.29 89 999999999 671.58 817.95 percent of total billed charges "ULTRASOUND, TRANSPLANTED KIDNEY, REAL TIME AND DUPLEX DOPPLER WITH IMAGE DOCUMENTATION" 9513539_1 CDM 402 RC 76776 HCPCS outpatient 861 645.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 766.29 89 999999999 671.58 817.95 percent of total billed charges "ULTRASOUND, TRANSPLANTED KIDNEY, REAL TIME AND DUPLEX DOPPLER WITH IMAGE DOCUMENTATION" 9513539_1 CDM 402 RC 76776 HCPCS outpatient 861 645.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 774.9 90 999999999 671.58 817.95 percent of total billed charges "ULTRASOUND, TRANSPLANTED KIDNEY, REAL TIME AND DUPLEX DOPPLER WITH IMAGE DOCUMENTATION" 9513539_1 CDM 402 RC 76776 HCPCS outpatient 861 645.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 817.95 95 999999999 671.58 817.95 percent of total billed charges "ULTRASOUND, TRANSPLANTED KIDNEY, REAL TIME AND DUPLEX DOPPLER WITH IMAGE DOCUMENTATION" 9513539_1 CDM 402 RC 76776 HCPCS outpatient 861 645.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 817.95 95 999999999 671.58 817.95 percent of total billed charges "ULTRASOUND, TRANSPLANTED KIDNEY, REAL TIME AND DUPLEX DOPPLER WITH IMAGE DOCUMENTATION" 9513539_1 CDM 402 RC 76776 HCPCS outpatient 861 645.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 766.29 89 999999999 671.58 817.95 percent of total billed charges "ULTRASOUND, TRANSPLANTED KIDNEY, REAL TIME AND DUPLEX DOPPLER WITH IMAGE DOCUMENTATION" 9513539_1 CDM 402 RC 76776 HCPCS outpatient 861 645.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 757.68 88 999999999 671.58 817.95 percent of total billed charges "ULTRASOUND, TRANSPLANTED KIDNEY, REAL TIME AND DUPLEX DOPPLER WITH IMAGE DOCUMENTATION" 9513539_1 CDM 402 RC 76776 HCPCS outpatient 861 645.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 766.29 89 999999999 671.58 817.95 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, FIRST TRIMESTER (< 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; SINGLE OR FIRST GESTATION" 9513545_1 CDM 402 RC 76801 HCPCS outpatient 1317 987.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1185.3 90 999999999 1027.26 1251.15 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, FIRST TRIMESTER (< 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; SINGLE OR FIRST GESTATION" 9513545_1 CDM 402 RC 76801 HCPCS outpatient 1317 987.75 AETNA MCR ADV AETNA MCR ADV 1027.26 78 999999999 1027.26 1251.15 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, FIRST TRIMESTER (< 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; SINGLE OR FIRST GESTATION" 9513545_1 CDM 402 RC 76801 HCPCS outpatient 1317 987.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1153.3 87.57 999999999 1027.26 1251.15 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, FIRST TRIMESTER (< 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; SINGLE OR FIRST GESTATION" 9513545_1 CDM 402 RC 76801 HCPCS outpatient 1317 987.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 1120.37 85.07 999999999 1027.26 1251.15 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, FIRST TRIMESTER (< 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; SINGLE OR FIRST GESTATION" 9513545_1 CDM 402 RC 76801 HCPCS outpatient 1317 987.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1120.37 85.07 999999999 1027.26 1251.15 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, FIRST TRIMESTER (< 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; SINGLE OR FIRST GESTATION" 9513545_1 CDM 402 RC 76801 HCPCS outpatient 1317 987.75 MOLINA MCAID MOLINA MCAID 1098.38 83.4 999999999 1027.26 1251.15 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, FIRST TRIMESTER (< 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; SINGLE OR FIRST GESTATION" 9513545_1 CDM 402 RC 76801 HCPCS outpatient 1317 987.75 MOLINA MCR ADV MOLINA MCR ADV 1172.13 89 999999999 1027.26 1251.15 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, FIRST TRIMESTER (< 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; SINGLE OR FIRST GESTATION" 9513545_1 CDM 402 RC 76801 HCPCS outpatient 1317 987.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1172.13 89 999999999 1027.26 1251.15 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, FIRST TRIMESTER (< 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; SINGLE OR FIRST GESTATION" 9513545_1 CDM 402 RC 76801 HCPCS outpatient 1317 987.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1172.13 89 999999999 1027.26 1251.15 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, FIRST TRIMESTER (< 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; SINGLE OR FIRST GESTATION" 9513545_1 CDM 402 RC 76801 HCPCS outpatient 1317 987.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1185.3 90 999999999 1027.26 1251.15 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, FIRST TRIMESTER (< 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; SINGLE OR FIRST GESTATION" 9513545_1 CDM 402 RC 76801 HCPCS outpatient 1317 987.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1251.15 95 999999999 1027.26 1251.15 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, FIRST TRIMESTER (< 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; SINGLE OR FIRST GESTATION" 9513545_1 CDM 402 RC 76801 HCPCS outpatient 1317 987.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1251.15 95 999999999 1027.26 1251.15 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, FIRST TRIMESTER (< 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; SINGLE OR FIRST GESTATION" 9513545_1 CDM 402 RC 76801 HCPCS outpatient 1317 987.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1172.13 89 999999999 1027.26 1251.15 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, FIRST TRIMESTER (< 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; SINGLE OR FIRST GESTATION" 9513545_1 CDM 402 RC 76801 HCPCS outpatient 1317 987.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1158.96 88 999999999 1027.26 1251.15 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, FIRST TRIMESTER (< 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; SINGLE OR FIRST GESTATION" 9513545_1 CDM 402 RC 76801 HCPCS outpatient 1317 987.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1172.13 89 999999999 1027.26 1251.15 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, FIRST TRIMESTER (< 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; EACH ADDITIONAL GESTATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9513548_1 CDM 402 RC 76802 HCPCS outpatient 1274 955.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1146.6 90 999999999 993.72 1210.3 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, FIRST TRIMESTER (< 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; EACH ADDITIONAL GESTATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9513548_1 CDM 402 RC 76802 HCPCS outpatient 1274 955.5 AETNA MCR ADV AETNA MCR ADV 993.72 78 999999999 993.72 1210.3 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, FIRST TRIMESTER (< 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; EACH ADDITIONAL GESTATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9513548_1 CDM 402 RC 76802 HCPCS outpatient 1274 955.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1115.64 87.57 999999999 993.72 1210.3 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, FIRST TRIMESTER (< 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; EACH ADDITIONAL GESTATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9513548_1 CDM 402 RC 76802 HCPCS outpatient 1274 955.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 1083.79 85.07 999999999 993.72 1210.3 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, FIRST TRIMESTER (< 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; EACH ADDITIONAL GESTATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9513548_1 CDM 402 RC 76802 HCPCS outpatient 1274 955.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1083.79 85.07 999999999 993.72 1210.3 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, FIRST TRIMESTER (< 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; EACH ADDITIONAL GESTATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9513548_1 CDM 402 RC 76802 HCPCS outpatient 1274 955.5 MOLINA MCAID MOLINA MCAID 1062.52 83.4 999999999 993.72 1210.3 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, FIRST TRIMESTER (< 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; EACH ADDITIONAL GESTATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9513548_1 CDM 402 RC 76802 HCPCS outpatient 1274 955.5 MOLINA MCR ADV MOLINA MCR ADV 1133.86 89 999999999 993.72 1210.3 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, FIRST TRIMESTER (< 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; EACH ADDITIONAL GESTATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9513548_1 CDM 402 RC 76802 HCPCS outpatient 1274 955.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1133.86 89 999999999 993.72 1210.3 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, FIRST TRIMESTER (< 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; EACH ADDITIONAL GESTATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9513548_1 CDM 402 RC 76802 HCPCS outpatient 1274 955.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1133.86 89 999999999 993.72 1210.3 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, FIRST TRIMESTER (< 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; EACH ADDITIONAL GESTATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9513548_1 CDM 402 RC 76802 HCPCS outpatient 1274 955.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1146.6 90 999999999 993.72 1210.3 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, FIRST TRIMESTER (< 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; EACH ADDITIONAL GESTATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9513548_1 CDM 402 RC 76802 HCPCS outpatient 1274 955.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1210.3 95 999999999 993.72 1210.3 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, FIRST TRIMESTER (< 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; EACH ADDITIONAL GESTATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9513548_1 CDM 402 RC 76802 HCPCS outpatient 1274 955.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1210.3 95 999999999 993.72 1210.3 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, FIRST TRIMESTER (< 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; EACH ADDITIONAL GESTATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9513548_1 CDM 402 RC 76802 HCPCS outpatient 1274 955.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1133.86 89 999999999 993.72 1210.3 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, FIRST TRIMESTER (< 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; EACH ADDITIONAL GESTATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9513548_1 CDM 402 RC 76802 HCPCS outpatient 1274 955.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1121.12 88 999999999 993.72 1210.3 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, FIRST TRIMESTER (< 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; EACH ADDITIONAL GESTATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9513548_1 CDM 402 RC 76802 HCPCS outpatient 1274 955.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1133.86 89 999999999 993.72 1210.3 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, AFTER FIRST TRIMESTER (> OR = 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; SINGLE OR FIRST GESTATION" 9513551_1 CDM 402 RC 76805 HCPCS outpatient 1713 1284.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1541.7 90 999999999 1336.14 1627.35 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, AFTER FIRST TRIMESTER (> OR = 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; SINGLE OR FIRST GESTATION" 9513551_1 CDM 402 RC 76805 HCPCS outpatient 1713 1284.75 AETNA MCR ADV AETNA MCR ADV 1336.14 78 999999999 1336.14 1627.35 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, AFTER FIRST TRIMESTER (> OR = 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; SINGLE OR FIRST GESTATION" 9513551_1 CDM 402 RC 76805 HCPCS outpatient 1713 1284.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1500.07 87.57 999999999 1336.14 1627.35 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, AFTER FIRST TRIMESTER (> OR = 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; SINGLE OR FIRST GESTATION" 9513551_1 CDM 402 RC 76805 HCPCS outpatient 1713 1284.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 1457.25 85.07 999999999 1336.14 1627.35 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, AFTER FIRST TRIMESTER (> OR = 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; SINGLE OR FIRST GESTATION" 9513551_1 CDM 402 RC 76805 HCPCS outpatient 1713 1284.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1457.25 85.07 999999999 1336.14 1627.35 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, AFTER FIRST TRIMESTER (> OR = 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; SINGLE OR FIRST GESTATION" 9513551_1 CDM 402 RC 76805 HCPCS outpatient 1713 1284.75 MOLINA MCAID MOLINA MCAID 1428.64 83.4 999999999 1336.14 1627.35 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, AFTER FIRST TRIMESTER (> OR = 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; SINGLE OR FIRST GESTATION" 9513551_1 CDM 402 RC 76805 HCPCS outpatient 1713 1284.75 MOLINA MCR ADV MOLINA MCR ADV 1524.57 89 999999999 1336.14 1627.35 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, AFTER FIRST TRIMESTER (> OR = 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; SINGLE OR FIRST GESTATION" 9513551_1 CDM 402 RC 76805 HCPCS outpatient 1713 1284.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1524.57 89 999999999 1336.14 1627.35 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, AFTER FIRST TRIMESTER (> OR = 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; SINGLE OR FIRST GESTATION" 9513551_1 CDM 402 RC 76805 HCPCS outpatient 1713 1284.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1524.57 89 999999999 1336.14 1627.35 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, AFTER FIRST TRIMESTER (> OR = 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; SINGLE OR FIRST GESTATION" 9513551_1 CDM 402 RC 76805 HCPCS outpatient 1713 1284.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1541.7 90 999999999 1336.14 1627.35 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, AFTER FIRST TRIMESTER (> OR = 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; SINGLE OR FIRST GESTATION" 9513551_1 CDM 402 RC 76805 HCPCS outpatient 1713 1284.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1627.35 95 999999999 1336.14 1627.35 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, AFTER FIRST TRIMESTER (> OR = 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; SINGLE OR FIRST GESTATION" 9513551_1 CDM 402 RC 76805 HCPCS outpatient 1713 1284.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1627.35 95 999999999 1336.14 1627.35 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, AFTER FIRST TRIMESTER (> OR = 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; SINGLE OR FIRST GESTATION" 9513551_1 CDM 402 RC 76805 HCPCS outpatient 1713 1284.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1524.57 89 999999999 1336.14 1627.35 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, AFTER FIRST TRIMESTER (> OR = 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; SINGLE OR FIRST GESTATION" 9513551_1 CDM 402 RC 76805 HCPCS outpatient 1713 1284.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1507.44 88 999999999 1336.14 1627.35 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, AFTER FIRST TRIMESTER (> OR = 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; SINGLE OR FIRST GESTATION" 9513551_1 CDM 402 RC 76805 HCPCS outpatient 1713 1284.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1524.57 89 999999999 1336.14 1627.35 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, LIMITED (EG, FETAL HEART BEAT, PLACENTAL LOCATION, FETAL POSITION AND/OR QUALITATIVE AMNIOTIC FLUID VOLUME), 1 OR MORE FETUSES" 9513569_1 CDM 402 RC 76815 HCPCS outpatient 820 615 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 738 90 999999999 639.6 779 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, LIMITED (EG, FETAL HEART BEAT, PLACENTAL LOCATION, FETAL POSITION AND/OR QUALITATIVE AMNIOTIC FLUID VOLUME), 1 OR MORE FETUSES" 9513569_1 CDM 402 RC 76815 HCPCS outpatient 820 615 AETNA MCR ADV AETNA MCR ADV 639.6 78 999999999 639.6 779 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, LIMITED (EG, FETAL HEART BEAT, PLACENTAL LOCATION, FETAL POSITION AND/OR QUALITATIVE AMNIOTIC FLUID VOLUME), 1 OR MORE FETUSES" 9513569_1 CDM 402 RC 76815 HCPCS outpatient 820 615 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 718.07 87.57 999999999 639.6 779 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, LIMITED (EG, FETAL HEART BEAT, PLACENTAL LOCATION, FETAL POSITION AND/OR QUALITATIVE AMNIOTIC FLUID VOLUME), 1 OR MORE FETUSES" 9513569_1 CDM 402 RC 76815 HCPCS outpatient 820 615 COORDINATED CARE MCAID COORDINATED CARE MCAID 697.57 85.07 999999999 639.6 779 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, LIMITED (EG, FETAL HEART BEAT, PLACENTAL LOCATION, FETAL POSITION AND/OR QUALITATIVE AMNIOTIC FLUID VOLUME), 1 OR MORE FETUSES" 9513569_1 CDM 402 RC 76815 HCPCS outpatient 820 615 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 697.57 85.07 999999999 639.6 779 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, LIMITED (EG, FETAL HEART BEAT, PLACENTAL LOCATION, FETAL POSITION AND/OR QUALITATIVE AMNIOTIC FLUID VOLUME), 1 OR MORE FETUSES" 9513569_1 CDM 402 RC 76815 HCPCS outpatient 820 615 MOLINA MCAID MOLINA MCAID 683.88 83.4 999999999 639.6 779 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, LIMITED (EG, FETAL HEART BEAT, PLACENTAL LOCATION, FETAL POSITION AND/OR QUALITATIVE AMNIOTIC FLUID VOLUME), 1 OR MORE FETUSES" 9513569_1 CDM 402 RC 76815 HCPCS outpatient 820 615 MOLINA MCR ADV MOLINA MCR ADV 729.8 89 999999999 639.6 779 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, LIMITED (EG, FETAL HEART BEAT, PLACENTAL LOCATION, FETAL POSITION AND/OR QUALITATIVE AMNIOTIC FLUID VOLUME), 1 OR MORE FETUSES" 9513569_1 CDM 402 RC 76815 HCPCS outpatient 820 615 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 729.8 89 999999999 639.6 779 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, LIMITED (EG, FETAL HEART BEAT, PLACENTAL LOCATION, FETAL POSITION AND/OR QUALITATIVE AMNIOTIC FLUID VOLUME), 1 OR MORE FETUSES" 9513569_1 CDM 402 RC 76815 HCPCS outpatient 820 615 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 729.8 89 999999999 639.6 779 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, LIMITED (EG, FETAL HEART BEAT, PLACENTAL LOCATION, FETAL POSITION AND/OR QUALITATIVE AMNIOTIC FLUID VOLUME), 1 OR MORE FETUSES" 9513569_1 CDM 402 RC 76815 HCPCS outpatient 820 615 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 738 90 999999999 639.6 779 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, LIMITED (EG, FETAL HEART BEAT, PLACENTAL LOCATION, FETAL POSITION AND/OR QUALITATIVE AMNIOTIC FLUID VOLUME), 1 OR MORE FETUSES" 9513569_1 CDM 402 RC 76815 HCPCS outpatient 820 615 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 779 95 999999999 639.6 779 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, LIMITED (EG, FETAL HEART BEAT, PLACENTAL LOCATION, FETAL POSITION AND/OR QUALITATIVE AMNIOTIC FLUID VOLUME), 1 OR MORE FETUSES" 9513569_1 CDM 402 RC 76815 HCPCS outpatient 820 615 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 779 95 999999999 639.6 779 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, LIMITED (EG, FETAL HEART BEAT, PLACENTAL LOCATION, FETAL POSITION AND/OR QUALITATIVE AMNIOTIC FLUID VOLUME), 1 OR MORE FETUSES" 9513569_1 CDM 402 RC 76815 HCPCS outpatient 820 615 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 729.8 89 999999999 639.6 779 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, LIMITED (EG, FETAL HEART BEAT, PLACENTAL LOCATION, FETAL POSITION AND/OR QUALITATIVE AMNIOTIC FLUID VOLUME), 1 OR MORE FETUSES" 9513569_1 CDM 402 RC 76815 HCPCS outpatient 820 615 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 721.6 88 999999999 639.6 779 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, LIMITED (EG, FETAL HEART BEAT, PLACENTAL LOCATION, FETAL POSITION AND/OR QUALITATIVE AMNIOTIC FLUID VOLUME), 1 OR MORE FETUSES" 9513569_1 CDM 402 RC 76815 HCPCS outpatient 820 615 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 729.8 89 999999999 639.6 779 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FOLLOW-UP (EG, RE-EVALUATION OF FETAL SIZE BY MEASURING STANDARD GROWTH PARAMETERS AND AMNIOTIC FLUID VOLUME, RE-EVALUATION OF ORGAN SYSTEM(S) SUSPECTED OR CONFIRMED TO BE ABNORMAL ON A PREVIOUS SCAN), TRANSABDOMINAL APPROACH, PER FETUS" 9513572_1 CDM 402 RC 76816 HCPCS outpatient 686 514.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 617.4 90 999999999 535.08 651.7 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FOLLOW-UP (EG, RE-EVALUATION OF FETAL SIZE BY MEASURING STANDARD GROWTH PARAMETERS AND AMNIOTIC FLUID VOLUME, RE-EVALUATION OF ORGAN SYSTEM(S) SUSPECTED OR CONFIRMED TO BE ABNORMAL ON A PREVIOUS SCAN), TRANSABDOMINAL APPROACH, PER FETUS" 9513572_1 CDM 402 RC 76816 HCPCS outpatient 686 514.5 AETNA MCR ADV AETNA MCR ADV 535.08 78 999999999 535.08 651.7 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FOLLOW-UP (EG, RE-EVALUATION OF FETAL SIZE BY MEASURING STANDARD GROWTH PARAMETERS AND AMNIOTIC FLUID VOLUME, RE-EVALUATION OF ORGAN SYSTEM(S) SUSPECTED OR CONFIRMED TO BE ABNORMAL ON A PREVIOUS SCAN), TRANSABDOMINAL APPROACH, PER FETUS" 9513572_1 CDM 402 RC 76816 HCPCS outpatient 686 514.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 600.73 87.57 999999999 535.08 651.7 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FOLLOW-UP (EG, RE-EVALUATION OF FETAL SIZE BY MEASURING STANDARD GROWTH PARAMETERS AND AMNIOTIC FLUID VOLUME, RE-EVALUATION OF ORGAN SYSTEM(S) SUSPECTED OR CONFIRMED TO BE ABNORMAL ON A PREVIOUS SCAN), TRANSABDOMINAL APPROACH, PER FETUS" 9513572_1 CDM 402 RC 76816 HCPCS outpatient 686 514.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 583.58 85.07 999999999 535.08 651.7 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FOLLOW-UP (EG, RE-EVALUATION OF FETAL SIZE BY MEASURING STANDARD GROWTH PARAMETERS AND AMNIOTIC FLUID VOLUME, RE-EVALUATION OF ORGAN SYSTEM(S) SUSPECTED OR CONFIRMED TO BE ABNORMAL ON A PREVIOUS SCAN), TRANSABDOMINAL APPROACH, PER FETUS" 9513572_1 CDM 402 RC 76816 HCPCS outpatient 686 514.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 583.58 85.07 999999999 535.08 651.7 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FOLLOW-UP (EG, RE-EVALUATION OF FETAL SIZE BY MEASURING STANDARD GROWTH PARAMETERS AND AMNIOTIC FLUID VOLUME, RE-EVALUATION OF ORGAN SYSTEM(S) SUSPECTED OR CONFIRMED TO BE ABNORMAL ON A PREVIOUS SCAN), TRANSABDOMINAL APPROACH, PER FETUS" 9513572_1 CDM 402 RC 76816 HCPCS outpatient 686 514.5 MOLINA MCAID MOLINA MCAID 572.12 83.4 999999999 535.08 651.7 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FOLLOW-UP (EG, RE-EVALUATION OF FETAL SIZE BY MEASURING STANDARD GROWTH PARAMETERS AND AMNIOTIC FLUID VOLUME, RE-EVALUATION OF ORGAN SYSTEM(S) SUSPECTED OR CONFIRMED TO BE ABNORMAL ON A PREVIOUS SCAN), TRANSABDOMINAL APPROACH, PER FETUS" 9513572_1 CDM 402 RC 76816 HCPCS outpatient 686 514.5 MOLINA MCR ADV MOLINA MCR ADV 610.54 89 999999999 535.08 651.7 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FOLLOW-UP (EG, RE-EVALUATION OF FETAL SIZE BY MEASURING STANDARD GROWTH PARAMETERS AND AMNIOTIC FLUID VOLUME, RE-EVALUATION OF ORGAN SYSTEM(S) SUSPECTED OR CONFIRMED TO BE ABNORMAL ON A PREVIOUS SCAN), TRANSABDOMINAL APPROACH, PER FETUS" 9513572_1 CDM 402 RC 76816 HCPCS outpatient 686 514.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 610.54 89 999999999 535.08 651.7 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FOLLOW-UP (EG, RE-EVALUATION OF FETAL SIZE BY MEASURING STANDARD GROWTH PARAMETERS AND AMNIOTIC FLUID VOLUME, RE-EVALUATION OF ORGAN SYSTEM(S) SUSPECTED OR CONFIRMED TO BE ABNORMAL ON A PREVIOUS SCAN), TRANSABDOMINAL APPROACH, PER FETUS" 9513572_1 CDM 402 RC 76816 HCPCS outpatient 686 514.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 610.54 89 999999999 535.08 651.7 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FOLLOW-UP (EG, RE-EVALUATION OF FETAL SIZE BY MEASURING STANDARD GROWTH PARAMETERS AND AMNIOTIC FLUID VOLUME, RE-EVALUATION OF ORGAN SYSTEM(S) SUSPECTED OR CONFIRMED TO BE ABNORMAL ON A PREVIOUS SCAN), TRANSABDOMINAL APPROACH, PER FETUS" 9513572_1 CDM 402 RC 76816 HCPCS outpatient 686 514.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 617.4 90 999999999 535.08 651.7 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FOLLOW-UP (EG, RE-EVALUATION OF FETAL SIZE BY MEASURING STANDARD GROWTH PARAMETERS AND AMNIOTIC FLUID VOLUME, RE-EVALUATION OF ORGAN SYSTEM(S) SUSPECTED OR CONFIRMED TO BE ABNORMAL ON A PREVIOUS SCAN), TRANSABDOMINAL APPROACH, PER FETUS" 9513572_1 CDM 402 RC 76816 HCPCS outpatient 686 514.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 651.7 95 999999999 535.08 651.7 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FOLLOW-UP (EG, RE-EVALUATION OF FETAL SIZE BY MEASURING STANDARD GROWTH PARAMETERS AND AMNIOTIC FLUID VOLUME, RE-EVALUATION OF ORGAN SYSTEM(S) SUSPECTED OR CONFIRMED TO BE ABNORMAL ON A PREVIOUS SCAN), TRANSABDOMINAL APPROACH, PER FETUS" 9513572_1 CDM 402 RC 76816 HCPCS outpatient 686 514.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 651.7 95 999999999 535.08 651.7 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FOLLOW-UP (EG, RE-EVALUATION OF FETAL SIZE BY MEASURING STANDARD GROWTH PARAMETERS AND AMNIOTIC FLUID VOLUME, RE-EVALUATION OF ORGAN SYSTEM(S) SUSPECTED OR CONFIRMED TO BE ABNORMAL ON A PREVIOUS SCAN), TRANSABDOMINAL APPROACH, PER FETUS" 9513572_1 CDM 402 RC 76816 HCPCS outpatient 686 514.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 610.54 89 999999999 535.08 651.7 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FOLLOW-UP (EG, RE-EVALUATION OF FETAL SIZE BY MEASURING STANDARD GROWTH PARAMETERS AND AMNIOTIC FLUID VOLUME, RE-EVALUATION OF ORGAN SYSTEM(S) SUSPECTED OR CONFIRMED TO BE ABNORMAL ON A PREVIOUS SCAN), TRANSABDOMINAL APPROACH, PER FETUS" 9513572_1 CDM 402 RC 76816 HCPCS outpatient 686 514.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 603.68 88 999999999 535.08 651.7 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FOLLOW-UP (EG, RE-EVALUATION OF FETAL SIZE BY MEASURING STANDARD GROWTH PARAMETERS AND AMNIOTIC FLUID VOLUME, RE-EVALUATION OF ORGAN SYSTEM(S) SUSPECTED OR CONFIRMED TO BE ABNORMAL ON A PREVIOUS SCAN), TRANSABDOMINAL APPROACH, PER FETUS" 9513572_1 CDM 402 RC 76816 HCPCS outpatient 686 514.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 610.54 89 999999999 535.08 651.7 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, TRANSVAGINAL" 9513575_1 CDM 402 RC 76817 HCPCS outpatient 1436 1077 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1292.4 90 999999999 1120.08 1364.2 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, TRANSVAGINAL" 9513575_1 CDM 402 RC 76817 HCPCS outpatient 1436 1077 AETNA MCR ADV AETNA MCR ADV 1120.08 78 999999999 1120.08 1364.2 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, TRANSVAGINAL" 9513575_1 CDM 402 RC 76817 HCPCS outpatient 1436 1077 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1257.51 87.57 999999999 1120.08 1364.2 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, TRANSVAGINAL" 9513575_1 CDM 402 RC 76817 HCPCS outpatient 1436 1077 COORDINATED CARE MCAID COORDINATED CARE MCAID 1221.61 85.07 999999999 1120.08 1364.2 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, TRANSVAGINAL" 9513575_1 CDM 402 RC 76817 HCPCS outpatient 1436 1077 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1221.61 85.07 999999999 1120.08 1364.2 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, TRANSVAGINAL" 9513575_1 CDM 402 RC 76817 HCPCS outpatient 1436 1077 MOLINA MCAID MOLINA MCAID 1197.62 83.4 999999999 1120.08 1364.2 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, TRANSVAGINAL" 9513575_1 CDM 402 RC 76817 HCPCS outpatient 1436 1077 MOLINA MCR ADV MOLINA MCR ADV 1278.04 89 999999999 1120.08 1364.2 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, TRANSVAGINAL" 9513575_1 CDM 402 RC 76817 HCPCS outpatient 1436 1077 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1278.04 89 999999999 1120.08 1364.2 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, TRANSVAGINAL" 9513575_1 CDM 402 RC 76817 HCPCS outpatient 1436 1077 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1278.04 89 999999999 1120.08 1364.2 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, TRANSVAGINAL" 9513575_1 CDM 402 RC 76817 HCPCS outpatient 1436 1077 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1292.4 90 999999999 1120.08 1364.2 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, TRANSVAGINAL" 9513575_1 CDM 402 RC 76817 HCPCS outpatient 1436 1077 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1364.2 95 999999999 1120.08 1364.2 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, TRANSVAGINAL" 9513575_1 CDM 402 RC 76817 HCPCS outpatient 1436 1077 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1364.2 95 999999999 1120.08 1364.2 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, TRANSVAGINAL" 9513575_1 CDM 402 RC 76817 HCPCS outpatient 1436 1077 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1278.04 89 999999999 1120.08 1364.2 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, TRANSVAGINAL" 9513575_1 CDM 402 RC 76817 HCPCS outpatient 1436 1077 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1263.68 88 999999999 1120.08 1364.2 percent of total billed charges "ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, TRANSVAGINAL" 9513575_1 CDM 402 RC 76817 HCPCS outpatient 1436 1077 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1278.04 89 999999999 1120.08 1364.2 percent of total billed charges FETAL BIOPHYSICAL PROFILE; WITH NON-STRESS TESTING 9513578_1 CDM 402 RC 76818 HCPCS outpatient 1212 909 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1090.8 90 999999999 945.36 1151.4 percent of total billed charges FETAL BIOPHYSICAL PROFILE; WITH NON-STRESS TESTING 9513578_1 CDM 402 RC 76818 HCPCS outpatient 1212 909 AETNA MCR ADV AETNA MCR ADV 945.36 78 999999999 945.36 1151.4 percent of total billed charges FETAL BIOPHYSICAL PROFILE; WITH NON-STRESS TESTING 9513578_1 CDM 402 RC 76818 HCPCS outpatient 1212 909 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1061.35 87.57 999999999 945.36 1151.4 percent of total billed charges FETAL BIOPHYSICAL PROFILE; WITH NON-STRESS TESTING 9513578_1 CDM 402 RC 76818 HCPCS outpatient 1212 909 COORDINATED CARE MCAID COORDINATED CARE MCAID 1031.05 85.07 999999999 945.36 1151.4 percent of total billed charges FETAL BIOPHYSICAL PROFILE; WITH NON-STRESS TESTING 9513578_1 CDM 402 RC 76818 HCPCS outpatient 1212 909 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1031.05 85.07 999999999 945.36 1151.4 percent of total billed charges FETAL BIOPHYSICAL PROFILE; WITH NON-STRESS TESTING 9513578_1 CDM 402 RC 76818 HCPCS outpatient 1212 909 MOLINA MCAID MOLINA MCAID 1010.81 83.4 999999999 945.36 1151.4 percent of total billed charges FETAL BIOPHYSICAL PROFILE; WITH NON-STRESS TESTING 9513578_1 CDM 402 RC 76818 HCPCS outpatient 1212 909 MOLINA MCR ADV MOLINA MCR ADV 1078.68 89 999999999 945.36 1151.4 percent of total billed charges FETAL BIOPHYSICAL PROFILE; WITH NON-STRESS TESTING 9513578_1 CDM 402 RC 76818 HCPCS outpatient 1212 909 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1078.68 89 999999999 945.36 1151.4 percent of total billed charges FETAL BIOPHYSICAL PROFILE; WITH NON-STRESS TESTING 9513578_1 CDM 402 RC 76818 HCPCS outpatient 1212 909 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1078.68 89 999999999 945.36 1151.4 percent of total billed charges FETAL BIOPHYSICAL PROFILE; WITH NON-STRESS TESTING 9513578_1 CDM 402 RC 76818 HCPCS outpatient 1212 909 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1090.8 90 999999999 945.36 1151.4 percent of total billed charges FETAL BIOPHYSICAL PROFILE; WITH NON-STRESS TESTING 9513578_1 CDM 402 RC 76818 HCPCS outpatient 1212 909 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1151.4 95 999999999 945.36 1151.4 percent of total billed charges FETAL BIOPHYSICAL PROFILE; WITH NON-STRESS TESTING 9513578_1 CDM 402 RC 76818 HCPCS outpatient 1212 909 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1151.4 95 999999999 945.36 1151.4 percent of total billed charges FETAL BIOPHYSICAL PROFILE; WITH NON-STRESS TESTING 9513578_1 CDM 402 RC 76818 HCPCS outpatient 1212 909 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1078.68 89 999999999 945.36 1151.4 percent of total billed charges FETAL BIOPHYSICAL PROFILE; WITH NON-STRESS TESTING 9513578_1 CDM 402 RC 76818 HCPCS outpatient 1212 909 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1066.56 88 999999999 945.36 1151.4 percent of total billed charges FETAL BIOPHYSICAL PROFILE; WITH NON-STRESS TESTING 9513578_1 CDM 402 RC 76818 HCPCS outpatient 1212 909 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1078.68 89 999999999 945.36 1151.4 percent of total billed charges "ULTRASOUND, TRANSVAGINAL" 9513599_1 CDM 402 RC 76830 HCPCS outpatient 685 513.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 616.5 90 999999999 534.3 650.75 percent of total billed charges "ULTRASOUND, TRANSVAGINAL" 9513599_1 CDM 402 RC 76830 HCPCS outpatient 685 513.75 AETNA MCR ADV AETNA MCR ADV 534.3 78 999999999 534.3 650.75 percent of total billed charges "ULTRASOUND, TRANSVAGINAL" 9513599_1 CDM 402 RC 76830 HCPCS outpatient 685 513.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 599.85 87.57 999999999 534.3 650.75 percent of total billed charges "ULTRASOUND, TRANSVAGINAL" 9513599_1 CDM 402 RC 76830 HCPCS outpatient 685 513.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 582.73 85.07 999999999 534.3 650.75 percent of total billed charges "ULTRASOUND, TRANSVAGINAL" 9513599_1 CDM 402 RC 76830 HCPCS outpatient 685 513.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 582.73 85.07 999999999 534.3 650.75 percent of total billed charges "ULTRASOUND, TRANSVAGINAL" 9513599_1 CDM 402 RC 76830 HCPCS outpatient 685 513.75 MOLINA MCAID MOLINA MCAID 571.29 83.4 999999999 534.3 650.75 percent of total billed charges "ULTRASOUND, TRANSVAGINAL" 9513599_1 CDM 402 RC 76830 HCPCS outpatient 685 513.75 MOLINA MCR ADV MOLINA MCR ADV 609.65 89 999999999 534.3 650.75 percent of total billed charges "ULTRASOUND, TRANSVAGINAL" 9513599_1 CDM 402 RC 76830 HCPCS outpatient 685 513.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 609.65 89 999999999 534.3 650.75 percent of total billed charges "ULTRASOUND, TRANSVAGINAL" 9513599_1 CDM 402 RC 76830 HCPCS outpatient 685 513.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 609.65 89 999999999 534.3 650.75 percent of total billed charges "ULTRASOUND, TRANSVAGINAL" 9513599_1 CDM 402 RC 76830 HCPCS outpatient 685 513.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 616.5 90 999999999 534.3 650.75 percent of total billed charges "ULTRASOUND, TRANSVAGINAL" 9513599_1 CDM 402 RC 76830 HCPCS outpatient 685 513.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 650.75 95 999999999 534.3 650.75 percent of total billed charges "ULTRASOUND, TRANSVAGINAL" 9513599_1 CDM 402 RC 76830 HCPCS outpatient 685 513.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 650.75 95 999999999 534.3 650.75 percent of total billed charges "ULTRASOUND, TRANSVAGINAL" 9513599_1 CDM 402 RC 76830 HCPCS outpatient 685 513.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 609.65 89 999999999 534.3 650.75 percent of total billed charges "ULTRASOUND, TRANSVAGINAL" 9513599_1 CDM 402 RC 76830 HCPCS outpatient 685 513.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 602.8 88 999999999 534.3 650.75 percent of total billed charges "ULTRASOUND, TRANSVAGINAL" 9513599_1 CDM 402 RC 76830 HCPCS outpatient 685 513.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 609.65 89 999999999 534.3 650.75 percent of total billed charges "ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513605_1 CDM 402 RC 76856 HCPCS outpatient 926 694.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 833.4 90 999999999 722.28 879.7 percent of total billed charges "ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513605_1 CDM 402 RC 76856 HCPCS outpatient 926 694.5 AETNA MCR ADV AETNA MCR ADV 722.28 78 999999999 722.28 879.7 percent of total billed charges "ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513605_1 CDM 402 RC 76856 HCPCS outpatient 926 694.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 810.9 87.57 999999999 722.28 879.7 percent of total billed charges "ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513605_1 CDM 402 RC 76856 HCPCS outpatient 926 694.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 787.75 85.07 999999999 722.28 879.7 percent of total billed charges "ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513605_1 CDM 402 RC 76856 HCPCS outpatient 926 694.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 787.75 85.07 999999999 722.28 879.7 percent of total billed charges "ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513605_1 CDM 402 RC 76856 HCPCS outpatient 926 694.5 MOLINA MCAID MOLINA MCAID 772.28 83.4 999999999 722.28 879.7 percent of total billed charges "ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513605_1 CDM 402 RC 76856 HCPCS outpatient 926 694.5 MOLINA MCR ADV MOLINA MCR ADV 824.14 89 999999999 722.28 879.7 percent of total billed charges "ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513605_1 CDM 402 RC 76856 HCPCS outpatient 926 694.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 824.14 89 999999999 722.28 879.7 percent of total billed charges "ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513605_1 CDM 402 RC 76856 HCPCS outpatient 926 694.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 824.14 89 999999999 722.28 879.7 percent of total billed charges "ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513605_1 CDM 402 RC 76856 HCPCS outpatient 926 694.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 833.4 90 999999999 722.28 879.7 percent of total billed charges "ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513605_1 CDM 402 RC 76856 HCPCS outpatient 926 694.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 879.7 95 999999999 722.28 879.7 percent of total billed charges "ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513605_1 CDM 402 RC 76856 HCPCS outpatient 926 694.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 879.7 95 999999999 722.28 879.7 percent of total billed charges "ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513605_1 CDM 402 RC 76856 HCPCS outpatient 926 694.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 824.14 89 999999999 722.28 879.7 percent of total billed charges "ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513605_1 CDM 402 RC 76856 HCPCS outpatient 926 694.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 814.88 88 999999999 722.28 879.7 percent of total billed charges "ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE" 9513605_1 CDM 402 RC 76856 HCPCS outpatient 926 694.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 824.14 89 999999999 722.28 879.7 percent of total billed charges "ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH IMAGE DOCUMENTATION; LIMITED OR FOLLOW-UP (EG, FOR FOLLICLES)" 9513608_1 CDM 402 RC 76857 HCPCS outpatient 655 491.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 589.5 90 999999999 510.9 622.25 percent of total billed charges "ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH IMAGE DOCUMENTATION; LIMITED OR FOLLOW-UP (EG, FOR FOLLICLES)" 9513608_1 CDM 402 RC 76857 HCPCS outpatient 655 491.25 AETNA MCR ADV AETNA MCR ADV 510.9 78 999999999 510.9 622.25 percent of total billed charges "ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH IMAGE DOCUMENTATION; LIMITED OR FOLLOW-UP (EG, FOR FOLLICLES)" 9513608_1 CDM 402 RC 76857 HCPCS outpatient 655 491.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 573.58 87.57 999999999 510.9 622.25 percent of total billed charges "ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH IMAGE DOCUMENTATION; LIMITED OR FOLLOW-UP (EG, FOR FOLLICLES)" 9513608_1 CDM 402 RC 76857 HCPCS outpatient 655 491.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 557.21 85.07 999999999 510.9 622.25 percent of total billed charges "ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH IMAGE DOCUMENTATION; LIMITED OR FOLLOW-UP (EG, FOR FOLLICLES)" 9513608_1 CDM 402 RC 76857 HCPCS outpatient 655 491.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 557.21 85.07 999999999 510.9 622.25 percent of total billed charges "ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH IMAGE DOCUMENTATION; LIMITED OR FOLLOW-UP (EG, FOR FOLLICLES)" 9513608_1 CDM 402 RC 76857 HCPCS outpatient 655 491.25 MOLINA MCAID MOLINA MCAID 546.27 83.4 999999999 510.9 622.25 percent of total billed charges "ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH IMAGE DOCUMENTATION; LIMITED OR FOLLOW-UP (EG, FOR FOLLICLES)" 9513608_1 CDM 402 RC 76857 HCPCS outpatient 655 491.25 MOLINA MCR ADV MOLINA MCR ADV 582.95 89 999999999 510.9 622.25 percent of total billed charges "ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH IMAGE DOCUMENTATION; LIMITED OR FOLLOW-UP (EG, FOR FOLLICLES)" 9513608_1 CDM 402 RC 76857 HCPCS outpatient 655 491.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 582.95 89 999999999 510.9 622.25 percent of total billed charges "ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH IMAGE DOCUMENTATION; LIMITED OR FOLLOW-UP (EG, FOR FOLLICLES)" 9513608_1 CDM 402 RC 76857 HCPCS outpatient 655 491.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 582.95 89 999999999 510.9 622.25 percent of total billed charges "ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH IMAGE DOCUMENTATION; LIMITED OR FOLLOW-UP (EG, FOR FOLLICLES)" 9513608_1 CDM 402 RC 76857 HCPCS outpatient 655 491.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 589.5 90 999999999 510.9 622.25 percent of total billed charges "ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH IMAGE DOCUMENTATION; LIMITED OR FOLLOW-UP (EG, FOR FOLLICLES)" 9513608_1 CDM 402 RC 76857 HCPCS outpatient 655 491.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 622.25 95 999999999 510.9 622.25 percent of total billed charges "ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH IMAGE DOCUMENTATION; LIMITED OR FOLLOW-UP (EG, FOR FOLLICLES)" 9513608_1 CDM 402 RC 76857 HCPCS outpatient 655 491.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 622.25 95 999999999 510.9 622.25 percent of total billed charges "ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH IMAGE DOCUMENTATION; LIMITED OR FOLLOW-UP (EG, FOR FOLLICLES)" 9513608_1 CDM 402 RC 76857 HCPCS outpatient 655 491.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 582.95 89 999999999 510.9 622.25 percent of total billed charges "ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH IMAGE DOCUMENTATION; LIMITED OR FOLLOW-UP (EG, FOR FOLLICLES)" 9513608_1 CDM 402 RC 76857 HCPCS outpatient 655 491.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 576.4 88 999999999 510.9 622.25 percent of total billed charges "ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH IMAGE DOCUMENTATION; LIMITED OR FOLLOW-UP (EG, FOR FOLLICLES)" 9513608_1 CDM 402 RC 76857 HCPCS outpatient 655 491.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 582.95 89 999999999 510.9 622.25 percent of total billed charges "ULTRASOUND, SCROTUM AND CONTENTS" 9513611_1 CDM 402 RC 76870 HCPCS outpatient 764 573 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 687.6 90 999999999 595.92 725.8 percent of total billed charges "ULTRASOUND, SCROTUM AND CONTENTS" 9513611_1 CDM 402 RC 76870 HCPCS outpatient 764 573 AETNA MCR ADV AETNA MCR ADV 595.92 78 999999999 595.92 725.8 percent of total billed charges "ULTRASOUND, SCROTUM AND CONTENTS" 9513611_1 CDM 402 RC 76870 HCPCS outpatient 764 573 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 669.03 87.57 999999999 595.92 725.8 percent of total billed charges "ULTRASOUND, SCROTUM AND CONTENTS" 9513611_1 CDM 402 RC 76870 HCPCS outpatient 764 573 COORDINATED CARE MCAID COORDINATED CARE MCAID 649.93 85.07 999999999 595.92 725.8 percent of total billed charges "ULTRASOUND, SCROTUM AND CONTENTS" 9513611_1 CDM 402 RC 76870 HCPCS outpatient 764 573 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 649.93 85.07 999999999 595.92 725.8 percent of total billed charges "ULTRASOUND, SCROTUM AND CONTENTS" 9513611_1 CDM 402 RC 76870 HCPCS outpatient 764 573 MOLINA MCAID MOLINA MCAID 637.18 83.4 999999999 595.92 725.8 percent of total billed charges "ULTRASOUND, SCROTUM AND CONTENTS" 9513611_1 CDM 402 RC 76870 HCPCS outpatient 764 573 MOLINA MCR ADV MOLINA MCR ADV 679.96 89 999999999 595.92 725.8 percent of total billed charges "ULTRASOUND, SCROTUM AND CONTENTS" 9513611_1 CDM 402 RC 76870 HCPCS outpatient 764 573 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 679.96 89 999999999 595.92 725.8 percent of total billed charges "ULTRASOUND, SCROTUM AND CONTENTS" 9513611_1 CDM 402 RC 76870 HCPCS outpatient 764 573 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 679.96 89 999999999 595.92 725.8 percent of total billed charges "ULTRASOUND, SCROTUM AND CONTENTS" 9513611_1 CDM 402 RC 76870 HCPCS outpatient 764 573 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 687.6 90 999999999 595.92 725.8 percent of total billed charges "ULTRASOUND, SCROTUM AND CONTENTS" 9513611_1 CDM 402 RC 76870 HCPCS outpatient 764 573 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 725.8 95 999999999 595.92 725.8 percent of total billed charges "ULTRASOUND, SCROTUM AND CONTENTS" 9513611_1 CDM 402 RC 76870 HCPCS outpatient 764 573 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 725.8 95 999999999 595.92 725.8 percent of total billed charges "ULTRASOUND, SCROTUM AND CONTENTS" 9513611_1 CDM 402 RC 76870 HCPCS outpatient 764 573 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 679.96 89 999999999 595.92 725.8 percent of total billed charges "ULTRASOUND, SCROTUM AND CONTENTS" 9513611_1 CDM 402 RC 76870 HCPCS outpatient 764 573 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 672.32 88 999999999 595.92 725.8 percent of total billed charges "ULTRASOUND, SCROTUM AND CONTENTS" 9513611_1 CDM 402 RC 76870 HCPCS outpatient 764 573 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 679.96 89 999999999 595.92 725.8 percent of total billed charges "ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), IMAGING SUPERVISION AND INTERPRETATION" 9513629_1 CDM 402 RC 76942 HCPCS outpatient 623 467.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 560.7 90 999999999 485.94 591.85 percent of total billed charges "ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), IMAGING SUPERVISION AND INTERPRETATION" 9513629_1 CDM 402 RC 76942 HCPCS outpatient 623 467.25 AETNA MCR ADV AETNA MCR ADV 485.94 78 999999999 485.94 591.85 percent of total billed charges "ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), IMAGING SUPERVISION AND INTERPRETATION" 9513629_1 CDM 402 RC 76942 HCPCS outpatient 623 467.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 545.56 87.57 999999999 485.94 591.85 percent of total billed charges "ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), IMAGING SUPERVISION AND INTERPRETATION" 9513629_1 CDM 402 RC 76942 HCPCS outpatient 623 467.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 529.99 85.07 999999999 485.94 591.85 percent of total billed charges "ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), IMAGING SUPERVISION AND INTERPRETATION" 9513629_1 CDM 402 RC 76942 HCPCS outpatient 623 467.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 529.99 85.07 999999999 485.94 591.85 percent of total billed charges "ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), IMAGING SUPERVISION AND INTERPRETATION" 9513629_1 CDM 402 RC 76942 HCPCS outpatient 623 467.25 MOLINA MCAID MOLINA MCAID 519.58 83.4 999999999 485.94 591.85 percent of total billed charges "ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), IMAGING SUPERVISION AND INTERPRETATION" 9513629_1 CDM 402 RC 76942 HCPCS outpatient 623 467.25 MOLINA MCR ADV MOLINA MCR ADV 554.47 89 999999999 485.94 591.85 percent of total billed charges "ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), IMAGING SUPERVISION AND INTERPRETATION" 9513629_1 CDM 402 RC 76942 HCPCS outpatient 623 467.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 554.47 89 999999999 485.94 591.85 percent of total billed charges "ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), IMAGING SUPERVISION AND INTERPRETATION" 9513629_1 CDM 402 RC 76942 HCPCS outpatient 623 467.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 554.47 89 999999999 485.94 591.85 percent of total billed charges "ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), IMAGING SUPERVISION AND INTERPRETATION" 9513629_1 CDM 402 RC 76942 HCPCS outpatient 623 467.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 560.7 90 999999999 485.94 591.85 percent of total billed charges "ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), IMAGING SUPERVISION AND INTERPRETATION" 9513629_1 CDM 402 RC 76942 HCPCS outpatient 623 467.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 591.85 95 999999999 485.94 591.85 percent of total billed charges "ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), IMAGING SUPERVISION AND INTERPRETATION" 9513629_1 CDM 402 RC 76942 HCPCS outpatient 623 467.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 591.85 95 999999999 485.94 591.85 percent of total billed charges "ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), IMAGING SUPERVISION AND INTERPRETATION" 9513629_1 CDM 402 RC 76942 HCPCS outpatient 623 467.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 554.47 89 999999999 485.94 591.85 percent of total billed charges "ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), IMAGING SUPERVISION AND INTERPRETATION" 9513629_1 CDM 402 RC 76942 HCPCS outpatient 623 467.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 548.24 88 999999999 485.94 591.85 percent of total billed charges "ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), IMAGING SUPERVISION AND INTERPRETATION" 9513629_1 CDM 402 RC 76942 HCPCS outpatient 623 467.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 554.47 89 999999999 485.94 591.85 percent of total billed charges "FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9513644_1 CDM 320 RC 77002 HCPCS outpatient 375 281.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 337.5 90 999999999 292.5 356.25 percent of total billed charges "FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9513644_1 CDM 320 RC 77002 HCPCS outpatient 375 281.25 AETNA MCR ADV AETNA MCR ADV 292.5 78 999999999 292.5 356.25 percent of total billed charges "FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9513644_1 CDM 320 RC 77002 HCPCS outpatient 375 281.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 328.39 87.57 999999999 292.5 356.25 percent of total billed charges "FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9513644_1 CDM 320 RC 77002 HCPCS outpatient 375 281.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 319.01 85.07 999999999 292.5 356.25 percent of total billed charges "FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9513644_1 CDM 320 RC 77002 HCPCS outpatient 375 281.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 319.01 85.07 999999999 292.5 356.25 percent of total billed charges "FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9513644_1 CDM 320 RC 77002 HCPCS outpatient 375 281.25 MOLINA MCAID MOLINA MCAID 312.75 83.4 999999999 292.5 356.25 percent of total billed charges "FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9513644_1 CDM 320 RC 77002 HCPCS outpatient 375 281.25 MOLINA MCR ADV MOLINA MCR ADV 333.75 89 999999999 292.5 356.25 percent of total billed charges "FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9513644_1 CDM 320 RC 77002 HCPCS outpatient 375 281.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 333.75 89 999999999 292.5 356.25 percent of total billed charges "FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9513644_1 CDM 320 RC 77002 HCPCS outpatient 375 281.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 333.75 89 999999999 292.5 356.25 percent of total billed charges "FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9513644_1 CDM 320 RC 77002 HCPCS outpatient 375 281.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 337.5 90 999999999 292.5 356.25 percent of total billed charges "FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9513644_1 CDM 320 RC 77002 HCPCS outpatient 375 281.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 356.25 95 999999999 292.5 356.25 percent of total billed charges "FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9513644_1 CDM 320 RC 77002 HCPCS outpatient 375 281.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 356.25 95 999999999 292.5 356.25 percent of total billed charges "FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9513644_1 CDM 320 RC 77002 HCPCS outpatient 375 281.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 333.75 89 999999999 292.5 356.25 percent of total billed charges "FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9513644_1 CDM 320 RC 77002 HCPCS outpatient 375 281.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 330 88 999999999 292.5 356.25 percent of total billed charges "FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9513644_1 CDM 320 RC 77002 HCPCS outpatient 375 281.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 333.75 89 999999999 292.5 356.25 percent of total billed charges FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER TIP FOR SPINE OR PARASPINOUS DIAGNOSTIC OR THERAPEUTIC INJECTION PROCEDURES (EPIDURAL OR SUBARACHNOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 9513647_1 CDM 320 RC 77003 HCPCS outpatient 715 536.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 643.5 90 999999999 557.7 679.25 percent of total billed charges FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER TIP FOR SPINE OR PARASPINOUS DIAGNOSTIC OR THERAPEUTIC INJECTION PROCEDURES (EPIDURAL OR SUBARACHNOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 9513647_1 CDM 320 RC 77003 HCPCS outpatient 715 536.25 AETNA MCR ADV AETNA MCR ADV 557.7 78 999999999 557.7 679.25 percent of total billed charges FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER TIP FOR SPINE OR PARASPINOUS DIAGNOSTIC OR THERAPEUTIC INJECTION PROCEDURES (EPIDURAL OR SUBARACHNOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 9513647_1 CDM 320 RC 77003 HCPCS outpatient 715 536.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 626.13 87.57 999999999 557.7 679.25 percent of total billed charges FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER TIP FOR SPINE OR PARASPINOUS DIAGNOSTIC OR THERAPEUTIC INJECTION PROCEDURES (EPIDURAL OR SUBARACHNOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 9513647_1 CDM 320 RC 77003 HCPCS outpatient 715 536.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 608.25 85.07 999999999 557.7 679.25 percent of total billed charges FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER TIP FOR SPINE OR PARASPINOUS DIAGNOSTIC OR THERAPEUTIC INJECTION PROCEDURES (EPIDURAL OR SUBARACHNOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 9513647_1 CDM 320 RC 77003 HCPCS outpatient 715 536.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 608.25 85.07 999999999 557.7 679.25 percent of total billed charges FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER TIP FOR SPINE OR PARASPINOUS DIAGNOSTIC OR THERAPEUTIC INJECTION PROCEDURES (EPIDURAL OR SUBARACHNOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 9513647_1 CDM 320 RC 77003 HCPCS outpatient 715 536.25 MOLINA MCAID MOLINA MCAID 596.31 83.4 999999999 557.7 679.25 percent of total billed charges FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER TIP FOR SPINE OR PARASPINOUS DIAGNOSTIC OR THERAPEUTIC INJECTION PROCEDURES (EPIDURAL OR SUBARACHNOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 9513647_1 CDM 320 RC 77003 HCPCS outpatient 715 536.25 MOLINA MCR ADV MOLINA MCR ADV 636.35 89 999999999 557.7 679.25 percent of total billed charges FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER TIP FOR SPINE OR PARASPINOUS DIAGNOSTIC OR THERAPEUTIC INJECTION PROCEDURES (EPIDURAL OR SUBARACHNOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 9513647_1 CDM 320 RC 77003 HCPCS outpatient 715 536.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 636.35 89 999999999 557.7 679.25 percent of total billed charges FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER TIP FOR SPINE OR PARASPINOUS DIAGNOSTIC OR THERAPEUTIC INJECTION PROCEDURES (EPIDURAL OR SUBARACHNOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 9513647_1 CDM 320 RC 77003 HCPCS outpatient 715 536.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 636.35 89 999999999 557.7 679.25 percent of total billed charges FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER TIP FOR SPINE OR PARASPINOUS DIAGNOSTIC OR THERAPEUTIC INJECTION PROCEDURES (EPIDURAL OR SUBARACHNOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 9513647_1 CDM 320 RC 77003 HCPCS outpatient 715 536.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 643.5 90 999999999 557.7 679.25 percent of total billed charges FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER TIP FOR SPINE OR PARASPINOUS DIAGNOSTIC OR THERAPEUTIC INJECTION PROCEDURES (EPIDURAL OR SUBARACHNOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 9513647_1 CDM 320 RC 77003 HCPCS outpatient 715 536.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 679.25 95 999999999 557.7 679.25 percent of total billed charges FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER TIP FOR SPINE OR PARASPINOUS DIAGNOSTIC OR THERAPEUTIC INJECTION PROCEDURES (EPIDURAL OR SUBARACHNOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 9513647_1 CDM 320 RC 77003 HCPCS outpatient 715 536.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 679.25 95 999999999 557.7 679.25 percent of total billed charges FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER TIP FOR SPINE OR PARASPINOUS DIAGNOSTIC OR THERAPEUTIC INJECTION PROCEDURES (EPIDURAL OR SUBARACHNOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 9513647_1 CDM 320 RC 77003 HCPCS outpatient 715 536.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 636.35 89 999999999 557.7 679.25 percent of total billed charges FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER TIP FOR SPINE OR PARASPINOUS DIAGNOSTIC OR THERAPEUTIC INJECTION PROCEDURES (EPIDURAL OR SUBARACHNOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 9513647_1 CDM 320 RC 77003 HCPCS outpatient 715 536.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 629.2 88 999999999 557.7 679.25 percent of total billed charges FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER TIP FOR SPINE OR PARASPINOUS DIAGNOSTIC OR THERAPEUTIC INJECTION PROCEDURES (EPIDURAL OR SUBARACHNOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 9513647_1 CDM 320 RC 77003 HCPCS outpatient 715 536.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 636.35 89 999999999 557.7 679.25 percent of total billed charges "RADIOLOGIC EXAMINATION, OSSEOUS SURVEY; COMPLETE (AXIAL AND APPENDICULAR SKELETON)" 9513698_1 CDM 320 RC 77075 HCPCS outpatient 400 300 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 360 90 999999999 312 380 percent of total billed charges "RADIOLOGIC EXAMINATION, OSSEOUS SURVEY; COMPLETE (AXIAL AND APPENDICULAR SKELETON)" 9513698_1 CDM 320 RC 77075 HCPCS outpatient 400 300 AETNA MCR ADV AETNA MCR ADV 312 78 999999999 312 380 percent of total billed charges "RADIOLOGIC EXAMINATION, OSSEOUS SURVEY; COMPLETE (AXIAL AND APPENDICULAR SKELETON)" 9513698_1 CDM 320 RC 77075 HCPCS outpatient 400 300 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 350.28 87.57 999999999 312 380 percent of total billed charges "RADIOLOGIC EXAMINATION, OSSEOUS SURVEY; COMPLETE (AXIAL AND APPENDICULAR SKELETON)" 9513698_1 CDM 320 RC 77075 HCPCS outpatient 400 300 COORDINATED CARE MCAID COORDINATED CARE MCAID 340.28 85.07 999999999 312 380 percent of total billed charges "RADIOLOGIC EXAMINATION, OSSEOUS SURVEY; COMPLETE (AXIAL AND APPENDICULAR SKELETON)" 9513698_1 CDM 320 RC 77075 HCPCS outpatient 400 300 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 340.28 85.07 999999999 312 380 percent of total billed charges "RADIOLOGIC EXAMINATION, OSSEOUS SURVEY; COMPLETE (AXIAL AND APPENDICULAR SKELETON)" 9513698_1 CDM 320 RC 77075 HCPCS outpatient 400 300 MOLINA MCAID MOLINA MCAID 333.6 83.4 999999999 312 380 percent of total billed charges "RADIOLOGIC EXAMINATION, OSSEOUS SURVEY; COMPLETE (AXIAL AND APPENDICULAR SKELETON)" 9513698_1 CDM 320 RC 77075 HCPCS outpatient 400 300 MOLINA MCR ADV MOLINA MCR ADV 356 89 999999999 312 380 percent of total billed charges "RADIOLOGIC EXAMINATION, OSSEOUS SURVEY; COMPLETE (AXIAL AND APPENDICULAR SKELETON)" 9513698_1 CDM 320 RC 77075 HCPCS outpatient 400 300 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 356 89 999999999 312 380 percent of total billed charges "RADIOLOGIC EXAMINATION, OSSEOUS SURVEY; COMPLETE (AXIAL AND APPENDICULAR SKELETON)" 9513698_1 CDM 320 RC 77075 HCPCS outpatient 400 300 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 356 89 999999999 312 380 percent of total billed charges "RADIOLOGIC EXAMINATION, OSSEOUS SURVEY; COMPLETE (AXIAL AND APPENDICULAR SKELETON)" 9513698_1 CDM 320 RC 77075 HCPCS outpatient 400 300 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 360 90 999999999 312 380 percent of total billed charges "RADIOLOGIC EXAMINATION, OSSEOUS SURVEY; COMPLETE (AXIAL AND APPENDICULAR SKELETON)" 9513698_1 CDM 320 RC 77075 HCPCS outpatient 400 300 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 380 95 999999999 312 380 percent of total billed charges "RADIOLOGIC EXAMINATION, OSSEOUS SURVEY; COMPLETE (AXIAL AND APPENDICULAR SKELETON)" 9513698_1 CDM 320 RC 77075 HCPCS outpatient 400 300 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 380 95 999999999 312 380 percent of total billed charges "RADIOLOGIC EXAMINATION, OSSEOUS SURVEY; COMPLETE (AXIAL AND APPENDICULAR SKELETON)" 9513698_1 CDM 320 RC 77075 HCPCS outpatient 400 300 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 356 89 999999999 312 380 percent of total billed charges "RADIOLOGIC EXAMINATION, OSSEOUS SURVEY; COMPLETE (AXIAL AND APPENDICULAR SKELETON)" 9513698_1 CDM 320 RC 77075 HCPCS outpatient 400 300 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 352 88 999999999 312 380 percent of total billed charges "RADIOLOGIC EXAMINATION, OSSEOUS SURVEY; COMPLETE (AXIAL AND APPENDICULAR SKELETON)" 9513698_1 CDM 320 RC 77075 HCPCS outpatient 400 300 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 356 89 999999999 312 380 percent of total billed charges DUPLEX SCAN OF EXTRACRANIAL ARTERIES; COMPLETE BILATERAL STUDY 9513969_1 CDM 921 RC 93880 HCPCS outpatient 1426 1069.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1283.4 90 999999999 1112.28 1354.7 percent of total billed charges DUPLEX SCAN OF EXTRACRANIAL ARTERIES; COMPLETE BILATERAL STUDY 9513969_1 CDM 921 RC 93880 HCPCS outpatient 1426 1069.5 AETNA MCR ADV AETNA MCR ADV 1112.28 78 999999999 1112.28 1354.7 percent of total billed charges DUPLEX SCAN OF EXTRACRANIAL ARTERIES; COMPLETE BILATERAL STUDY 9513969_1 CDM 921 RC 93880 HCPCS outpatient 1426 1069.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1248.75 87.57 999999999 1112.28 1354.7 percent of total billed charges DUPLEX SCAN OF EXTRACRANIAL ARTERIES; COMPLETE BILATERAL STUDY 9513969_1 CDM 921 RC 93880 HCPCS outpatient 1426 1069.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 1213.1 85.07 999999999 1112.28 1354.7 percent of total billed charges DUPLEX SCAN OF EXTRACRANIAL ARTERIES; COMPLETE BILATERAL STUDY 9513969_1 CDM 921 RC 93880 HCPCS outpatient 1426 1069.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1213.1 85.07 999999999 1112.28 1354.7 percent of total billed charges DUPLEX SCAN OF EXTRACRANIAL ARTERIES; COMPLETE BILATERAL STUDY 9513969_1 CDM 921 RC 93880 HCPCS outpatient 1426 1069.5 MOLINA MCAID MOLINA MCAID 1189.28 83.4 999999999 1112.28 1354.7 percent of total billed charges DUPLEX SCAN OF EXTRACRANIAL ARTERIES; COMPLETE BILATERAL STUDY 9513969_1 CDM 921 RC 93880 HCPCS outpatient 1426 1069.5 MOLINA MCR ADV MOLINA MCR ADV 1269.14 89 999999999 1112.28 1354.7 percent of total billed charges DUPLEX SCAN OF EXTRACRANIAL ARTERIES; COMPLETE BILATERAL STUDY 9513969_1 CDM 921 RC 93880 HCPCS outpatient 1426 1069.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1269.14 89 999999999 1112.28 1354.7 percent of total billed charges DUPLEX SCAN OF EXTRACRANIAL ARTERIES; COMPLETE BILATERAL STUDY 9513969_1 CDM 921 RC 93880 HCPCS outpatient 1426 1069.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1269.14 89 999999999 1112.28 1354.7 percent of total billed charges DUPLEX SCAN OF EXTRACRANIAL ARTERIES; COMPLETE BILATERAL STUDY 9513969_1 CDM 921 RC 93880 HCPCS outpatient 1426 1069.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1283.4 90 999999999 1112.28 1354.7 percent of total billed charges DUPLEX SCAN OF EXTRACRANIAL ARTERIES; COMPLETE BILATERAL STUDY 9513969_1 CDM 921 RC 93880 HCPCS outpatient 1426 1069.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1354.7 95 999999999 1112.28 1354.7 percent of total billed charges DUPLEX SCAN OF EXTRACRANIAL ARTERIES; COMPLETE BILATERAL STUDY 9513969_1 CDM 921 RC 93880 HCPCS outpatient 1426 1069.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1354.7 95 999999999 1112.28 1354.7 percent of total billed charges DUPLEX SCAN OF EXTRACRANIAL ARTERIES; COMPLETE BILATERAL STUDY 9513969_1 CDM 921 RC 93880 HCPCS outpatient 1426 1069.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1269.14 89 999999999 1112.28 1354.7 percent of total billed charges DUPLEX SCAN OF EXTRACRANIAL ARTERIES; COMPLETE BILATERAL STUDY 9513969_1 CDM 921 RC 93880 HCPCS outpatient 1426 1069.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1254.88 88 999999999 1112.28 1354.7 percent of total billed charges DUPLEX SCAN OF EXTRACRANIAL ARTERIES; COMPLETE BILATERAL STUDY 9513969_1 CDM 921 RC 93880 HCPCS outpatient 1426 1069.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1269.14 89 999999999 1112.28 1354.7 percent of total billed charges "COMPLETE BILATERAL NONINVASIVE PHYSIOLOGIC STUDIES OF UPPER OR LOWER EXTREMITY ARTERIES, 3 OR MORE LEVELS (EG, FOR LOWER EXTREMITY: ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL BLOOD PRESSURE MEASUREMENTS WITH BIDIRECTIONAL DOPPLER WAVEFORM RECORDING AND ANALYSIS, AT 3 OR MORE LEVELS, OR ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL VOLUME PLETHYSMOGRAPHY AT 3 OR MORE LEVELS, OR ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL TRANSCUTANEOUS OXYGEN TENSION MEASUREMENTS AT 3 OR MORE LEVELS), OR SINGLE LEVEL STUDY WITH PROVOCATIVE FUNCTIONAL MANEUVERS (EG, MEASUREMENTS WITH POSTURAL PROVOCATIVE TESTS, OR MEASUREMENTS WITH REACTIVE HYPEREMIA)" 9513990_1 CDM 921 RC 93923 HCPCS outpatient 628 471 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 565.2 90 999999999 489.84 596.6 percent of total billed charges "COMPLETE BILATERAL NONINVASIVE PHYSIOLOGIC STUDIES OF UPPER OR LOWER EXTREMITY ARTERIES, 3 OR MORE LEVELS (EG, FOR LOWER EXTREMITY: ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL BLOOD PRESSURE MEASUREMENTS WITH BIDIRECTIONAL DOPPLER WAVEFORM RECORDING AND ANALYSIS, AT 3 OR MORE LEVELS, OR ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL VOLUME PLETHYSMOGRAPHY AT 3 OR MORE LEVELS, OR ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL TRANSCUTANEOUS OXYGEN TENSION MEASUREMENTS AT 3 OR MORE LEVELS), OR SINGLE LEVEL STUDY WITH PROVOCATIVE FUNCTIONAL MANEUVERS (EG, MEASUREMENTS WITH POSTURAL PROVOCATIVE TESTS, OR MEASUREMENTS WITH REACTIVE HYPEREMIA)" 9513990_1 CDM 921 RC 93923 HCPCS outpatient 628 471 AETNA MCR ADV AETNA MCR ADV 489.84 78 999999999 489.84 596.6 percent of total billed charges "COMPLETE BILATERAL NONINVASIVE PHYSIOLOGIC STUDIES OF UPPER OR LOWER EXTREMITY ARTERIES, 3 OR MORE LEVELS (EG, FOR LOWER EXTREMITY: ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL BLOOD PRESSURE MEASUREMENTS WITH BIDIRECTIONAL DOPPLER WAVEFORM RECORDING AND ANALYSIS, AT 3 OR MORE LEVELS, OR ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL VOLUME PLETHYSMOGRAPHY AT 3 OR MORE LEVELS, OR ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL TRANSCUTANEOUS OXYGEN TENSION MEASUREMENTS AT 3 OR MORE LEVELS), OR SINGLE LEVEL STUDY WITH PROVOCATIVE FUNCTIONAL MANEUVERS (EG, MEASUREMENTS WITH POSTURAL PROVOCATIVE TESTS, OR MEASUREMENTS WITH REACTIVE HYPEREMIA)" 9513990_1 CDM 921 RC 93923 HCPCS outpatient 628 471 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 549.94 87.57 999999999 489.84 596.6 percent of total billed charges "COMPLETE BILATERAL NONINVASIVE PHYSIOLOGIC STUDIES OF UPPER OR LOWER EXTREMITY ARTERIES, 3 OR MORE LEVELS (EG, FOR LOWER EXTREMITY: ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL BLOOD PRESSURE MEASUREMENTS WITH BIDIRECTIONAL DOPPLER WAVEFORM RECORDING AND ANALYSIS, AT 3 OR MORE LEVELS, OR ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL VOLUME PLETHYSMOGRAPHY AT 3 OR MORE LEVELS, OR ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL TRANSCUTANEOUS OXYGEN TENSION MEASUREMENTS AT 3 OR MORE LEVELS), OR SINGLE LEVEL STUDY WITH PROVOCATIVE FUNCTIONAL MANEUVERS (EG, MEASUREMENTS WITH POSTURAL PROVOCATIVE TESTS, OR MEASUREMENTS WITH REACTIVE HYPEREMIA)" 9513990_1 CDM 921 RC 93923 HCPCS outpatient 628 471 COORDINATED CARE MCAID COORDINATED CARE MCAID 534.24 85.07 999999999 489.84 596.6 percent of total billed charges "COMPLETE BILATERAL NONINVASIVE PHYSIOLOGIC STUDIES OF UPPER OR LOWER EXTREMITY ARTERIES, 3 OR MORE LEVELS (EG, FOR LOWER EXTREMITY: ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL BLOOD PRESSURE MEASUREMENTS WITH BIDIRECTIONAL DOPPLER WAVEFORM RECORDING AND ANALYSIS, AT 3 OR MORE LEVELS, OR ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL VOLUME PLETHYSMOGRAPHY AT 3 OR MORE LEVELS, OR ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL TRANSCUTANEOUS OXYGEN TENSION MEASUREMENTS AT 3 OR MORE LEVELS), OR SINGLE LEVEL STUDY WITH PROVOCATIVE FUNCTIONAL MANEUVERS (EG, MEASUREMENTS WITH POSTURAL PROVOCATIVE TESTS, OR MEASUREMENTS WITH REACTIVE HYPEREMIA)" 9513990_1 CDM 921 RC 93923 HCPCS outpatient 628 471 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 534.24 85.07 999999999 489.84 596.6 percent of total billed charges "COMPLETE BILATERAL NONINVASIVE PHYSIOLOGIC STUDIES OF UPPER OR LOWER EXTREMITY ARTERIES, 3 OR MORE LEVELS (EG, FOR LOWER EXTREMITY: ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL BLOOD PRESSURE MEASUREMENTS WITH BIDIRECTIONAL DOPPLER WAVEFORM RECORDING AND ANALYSIS, AT 3 OR MORE LEVELS, OR ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL VOLUME PLETHYSMOGRAPHY AT 3 OR MORE LEVELS, OR ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL TRANSCUTANEOUS OXYGEN TENSION MEASUREMENTS AT 3 OR MORE LEVELS), OR SINGLE LEVEL STUDY WITH PROVOCATIVE FUNCTIONAL MANEUVERS (EG, MEASUREMENTS WITH POSTURAL PROVOCATIVE TESTS, OR MEASUREMENTS WITH REACTIVE HYPEREMIA)" 9513990_1 CDM 921 RC 93923 HCPCS outpatient 628 471 MOLINA MCAID MOLINA MCAID 523.75 83.4 999999999 489.84 596.6 percent of total billed charges "COMPLETE BILATERAL NONINVASIVE PHYSIOLOGIC STUDIES OF UPPER OR LOWER EXTREMITY ARTERIES, 3 OR MORE LEVELS (EG, FOR LOWER EXTREMITY: ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL BLOOD PRESSURE MEASUREMENTS WITH BIDIRECTIONAL DOPPLER WAVEFORM RECORDING AND ANALYSIS, AT 3 OR MORE LEVELS, OR ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL VOLUME PLETHYSMOGRAPHY AT 3 OR MORE LEVELS, OR ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL TRANSCUTANEOUS OXYGEN TENSION MEASUREMENTS AT 3 OR MORE LEVELS), OR SINGLE LEVEL STUDY WITH PROVOCATIVE FUNCTIONAL MANEUVERS (EG, MEASUREMENTS WITH POSTURAL PROVOCATIVE TESTS, OR MEASUREMENTS WITH REACTIVE HYPEREMIA)" 9513990_1 CDM 921 RC 93923 HCPCS outpatient 628 471 MOLINA MCR ADV MOLINA MCR ADV 558.92 89 999999999 489.84 596.6 percent of total billed charges "COMPLETE BILATERAL NONINVASIVE PHYSIOLOGIC STUDIES OF UPPER OR LOWER EXTREMITY ARTERIES, 3 OR MORE LEVELS (EG, FOR LOWER EXTREMITY: ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL BLOOD PRESSURE MEASUREMENTS WITH BIDIRECTIONAL DOPPLER WAVEFORM RECORDING AND ANALYSIS, AT 3 OR MORE LEVELS, OR ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL VOLUME PLETHYSMOGRAPHY AT 3 OR MORE LEVELS, OR ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL TRANSCUTANEOUS OXYGEN TENSION MEASUREMENTS AT 3 OR MORE LEVELS), OR SINGLE LEVEL STUDY WITH PROVOCATIVE FUNCTIONAL MANEUVERS (EG, MEASUREMENTS WITH POSTURAL PROVOCATIVE TESTS, OR MEASUREMENTS WITH REACTIVE HYPEREMIA)" 9513990_1 CDM 921 RC 93923 HCPCS outpatient 628 471 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 558.92 89 999999999 489.84 596.6 percent of total billed charges "COMPLETE BILATERAL NONINVASIVE PHYSIOLOGIC STUDIES OF UPPER OR LOWER EXTREMITY ARTERIES, 3 OR MORE LEVELS (EG, FOR LOWER EXTREMITY: ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL BLOOD PRESSURE MEASUREMENTS WITH BIDIRECTIONAL DOPPLER WAVEFORM RECORDING AND ANALYSIS, AT 3 OR MORE LEVELS, OR ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL VOLUME PLETHYSMOGRAPHY AT 3 OR MORE LEVELS, OR ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL TRANSCUTANEOUS OXYGEN TENSION MEASUREMENTS AT 3 OR MORE LEVELS), OR SINGLE LEVEL STUDY WITH PROVOCATIVE FUNCTIONAL MANEUVERS (EG, MEASUREMENTS WITH POSTURAL PROVOCATIVE TESTS, OR MEASUREMENTS WITH REACTIVE HYPEREMIA)" 9513990_1 CDM 921 RC 93923 HCPCS outpatient 628 471 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 558.92 89 999999999 489.84 596.6 percent of total billed charges "COMPLETE BILATERAL NONINVASIVE PHYSIOLOGIC STUDIES OF UPPER OR LOWER EXTREMITY ARTERIES, 3 OR MORE LEVELS (EG, FOR LOWER EXTREMITY: ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL BLOOD PRESSURE MEASUREMENTS WITH BIDIRECTIONAL DOPPLER WAVEFORM RECORDING AND ANALYSIS, AT 3 OR MORE LEVELS, OR ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL VOLUME PLETHYSMOGRAPHY AT 3 OR MORE LEVELS, OR ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL TRANSCUTANEOUS OXYGEN TENSION MEASUREMENTS AT 3 OR MORE LEVELS), OR SINGLE LEVEL STUDY WITH PROVOCATIVE FUNCTIONAL MANEUVERS (EG, MEASUREMENTS WITH POSTURAL PROVOCATIVE TESTS, OR MEASUREMENTS WITH REACTIVE HYPEREMIA)" 9513990_1 CDM 921 RC 93923 HCPCS outpatient 628 471 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 565.2 90 999999999 489.84 596.6 percent of total billed charges "COMPLETE BILATERAL NONINVASIVE PHYSIOLOGIC STUDIES OF UPPER OR LOWER EXTREMITY ARTERIES, 3 OR MORE LEVELS (EG, FOR LOWER EXTREMITY: ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL BLOOD PRESSURE MEASUREMENTS WITH BIDIRECTIONAL DOPPLER WAVEFORM RECORDING AND ANALYSIS, AT 3 OR MORE LEVELS, OR ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL VOLUME PLETHYSMOGRAPHY AT 3 OR MORE LEVELS, OR ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL TRANSCUTANEOUS OXYGEN TENSION MEASUREMENTS AT 3 OR MORE LEVELS), OR SINGLE LEVEL STUDY WITH PROVOCATIVE FUNCTIONAL MANEUVERS (EG, MEASUREMENTS WITH POSTURAL PROVOCATIVE TESTS, OR MEASUREMENTS WITH REACTIVE HYPEREMIA)" 9513990_1 CDM 921 RC 93923 HCPCS outpatient 628 471 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 596.6 95 999999999 489.84 596.6 percent of total billed charges "COMPLETE BILATERAL NONINVASIVE PHYSIOLOGIC STUDIES OF UPPER OR LOWER EXTREMITY ARTERIES, 3 OR MORE LEVELS (EG, FOR LOWER EXTREMITY: ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL BLOOD PRESSURE MEASUREMENTS WITH BIDIRECTIONAL DOPPLER WAVEFORM RECORDING AND ANALYSIS, AT 3 OR MORE LEVELS, OR ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL VOLUME PLETHYSMOGRAPHY AT 3 OR MORE LEVELS, OR ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL TRANSCUTANEOUS OXYGEN TENSION MEASUREMENTS AT 3 OR MORE LEVELS), OR SINGLE LEVEL STUDY WITH PROVOCATIVE FUNCTIONAL MANEUVERS (EG, MEASUREMENTS WITH POSTURAL PROVOCATIVE TESTS, OR MEASUREMENTS WITH REACTIVE HYPEREMIA)" 9513990_1 CDM 921 RC 93923 HCPCS outpatient 628 471 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 596.6 95 999999999 489.84 596.6 percent of total billed charges "COMPLETE BILATERAL NONINVASIVE PHYSIOLOGIC STUDIES OF UPPER OR LOWER EXTREMITY ARTERIES, 3 OR MORE LEVELS (EG, FOR LOWER EXTREMITY: ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL BLOOD PRESSURE MEASUREMENTS WITH BIDIRECTIONAL DOPPLER WAVEFORM RECORDING AND ANALYSIS, AT 3 OR MORE LEVELS, OR ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL VOLUME PLETHYSMOGRAPHY AT 3 OR MORE LEVELS, OR ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL TRANSCUTANEOUS OXYGEN TENSION MEASUREMENTS AT 3 OR MORE LEVELS), OR SINGLE LEVEL STUDY WITH PROVOCATIVE FUNCTIONAL MANEUVERS (EG, MEASUREMENTS WITH POSTURAL PROVOCATIVE TESTS, OR MEASUREMENTS WITH REACTIVE HYPEREMIA)" 9513990_1 CDM 921 RC 93923 HCPCS outpatient 628 471 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 558.92 89 999999999 489.84 596.6 percent of total billed charges "COMPLETE BILATERAL NONINVASIVE PHYSIOLOGIC STUDIES OF UPPER OR LOWER EXTREMITY ARTERIES, 3 OR MORE LEVELS (EG, FOR LOWER EXTREMITY: ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL BLOOD PRESSURE MEASUREMENTS WITH BIDIRECTIONAL DOPPLER WAVEFORM RECORDING AND ANALYSIS, AT 3 OR MORE LEVELS, OR ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL VOLUME PLETHYSMOGRAPHY AT 3 OR MORE LEVELS, OR ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL TRANSCUTANEOUS OXYGEN TENSION MEASUREMENTS AT 3 OR MORE LEVELS), OR SINGLE LEVEL STUDY WITH PROVOCATIVE FUNCTIONAL MANEUVERS (EG, MEASUREMENTS WITH POSTURAL PROVOCATIVE TESTS, OR MEASUREMENTS WITH REACTIVE HYPEREMIA)" 9513990_1 CDM 921 RC 93923 HCPCS outpatient 628 471 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 552.64 88 999999999 489.84 596.6 percent of total billed charges "COMPLETE BILATERAL NONINVASIVE PHYSIOLOGIC STUDIES OF UPPER OR LOWER EXTREMITY ARTERIES, 3 OR MORE LEVELS (EG, FOR LOWER EXTREMITY: ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL BLOOD PRESSURE MEASUREMENTS WITH BIDIRECTIONAL DOPPLER WAVEFORM RECORDING AND ANALYSIS, AT 3 OR MORE LEVELS, OR ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL VOLUME PLETHYSMOGRAPHY AT 3 OR MORE LEVELS, OR ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS SEGMENTAL TRANSCUTANEOUS OXYGEN TENSION MEASUREMENTS AT 3 OR MORE LEVELS), OR SINGLE LEVEL STUDY WITH PROVOCATIVE FUNCTIONAL MANEUVERS (EG, MEASUREMENTS WITH POSTURAL PROVOCATIVE TESTS, OR MEASUREMENTS WITH REACTIVE HYPEREMIA)" 9513990_1 CDM 921 RC 93923 HCPCS outpatient 628 471 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 558.92 89 999999999 489.84 596.6 percent of total billed charges DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; COMPLETE BILATERAL STUDY 9513996_1 CDM 921 RC 93925 HCPCS outpatient 1138 853.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1024.2 90 999999999 887.64 1081.1 percent of total billed charges DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; COMPLETE BILATERAL STUDY 9513996_1 CDM 921 RC 93925 HCPCS outpatient 1138 853.5 AETNA MCR ADV AETNA MCR ADV 887.64 78 999999999 887.64 1081.1 percent of total billed charges DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; COMPLETE BILATERAL STUDY 9513996_1 CDM 921 RC 93925 HCPCS outpatient 1138 853.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 996.55 87.57 999999999 887.64 1081.1 percent of total billed charges DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; COMPLETE BILATERAL STUDY 9513996_1 CDM 921 RC 93925 HCPCS outpatient 1138 853.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 968.1 85.07 999999999 887.64 1081.1 percent of total billed charges DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; COMPLETE BILATERAL STUDY 9513996_1 CDM 921 RC 93925 HCPCS outpatient 1138 853.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 968.1 85.07 999999999 887.64 1081.1 percent of total billed charges DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; COMPLETE BILATERAL STUDY 9513996_1 CDM 921 RC 93925 HCPCS outpatient 1138 853.5 MOLINA MCAID MOLINA MCAID 949.09 83.4 999999999 887.64 1081.1 percent of total billed charges DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; COMPLETE BILATERAL STUDY 9513996_1 CDM 921 RC 93925 HCPCS outpatient 1138 853.5 MOLINA MCR ADV MOLINA MCR ADV 1012.82 89 999999999 887.64 1081.1 percent of total billed charges DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; COMPLETE BILATERAL STUDY 9513996_1 CDM 921 RC 93925 HCPCS outpatient 1138 853.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1012.82 89 999999999 887.64 1081.1 percent of total billed charges DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; COMPLETE BILATERAL STUDY 9513996_1 CDM 921 RC 93925 HCPCS outpatient 1138 853.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1012.82 89 999999999 887.64 1081.1 percent of total billed charges DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; COMPLETE BILATERAL STUDY 9513996_1 CDM 921 RC 93925 HCPCS outpatient 1138 853.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1024.2 90 999999999 887.64 1081.1 percent of total billed charges DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; COMPLETE BILATERAL STUDY 9513996_1 CDM 921 RC 93925 HCPCS outpatient 1138 853.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1081.1 95 999999999 887.64 1081.1 percent of total billed charges DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; COMPLETE BILATERAL STUDY 9513996_1 CDM 921 RC 93925 HCPCS outpatient 1138 853.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1081.1 95 999999999 887.64 1081.1 percent of total billed charges DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; COMPLETE BILATERAL STUDY 9513996_1 CDM 921 RC 93925 HCPCS outpatient 1138 853.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1012.82 89 999999999 887.64 1081.1 percent of total billed charges DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; COMPLETE BILATERAL STUDY 9513996_1 CDM 921 RC 93925 HCPCS outpatient 1138 853.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1001.44 88 999999999 887.64 1081.1 percent of total billed charges DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; COMPLETE BILATERAL STUDY 9513996_1 CDM 921 RC 93925 HCPCS outpatient 1138 853.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1012.82 89 999999999 887.64 1081.1 percent of total billed charges DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY 9513999_1 CDM 921 RC 93926 HCPCS outpatient 855 641.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 769.5 90 999999999 666.9 812.25 percent of total billed charges DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY 9513999_1 CDM 921 RC 93926 HCPCS outpatient 855 641.25 AETNA MCR ADV AETNA MCR ADV 666.9 78 999999999 666.9 812.25 percent of total billed charges DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY 9513999_1 CDM 921 RC 93926 HCPCS outpatient 855 641.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 748.72 87.57 999999999 666.9 812.25 percent of total billed charges DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY 9513999_1 CDM 921 RC 93926 HCPCS outpatient 855 641.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 727.35 85.07 999999999 666.9 812.25 percent of total billed charges DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY 9513999_1 CDM 921 RC 93926 HCPCS outpatient 855 641.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 727.35 85.07 999999999 666.9 812.25 percent of total billed charges DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY 9513999_1 CDM 921 RC 93926 HCPCS outpatient 855 641.25 MOLINA MCAID MOLINA MCAID 713.07 83.4 999999999 666.9 812.25 percent of total billed charges DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY 9513999_1 CDM 921 RC 93926 HCPCS outpatient 855 641.25 MOLINA MCR ADV MOLINA MCR ADV 760.95 89 999999999 666.9 812.25 percent of total billed charges DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY 9513999_1 CDM 921 RC 93926 HCPCS outpatient 855 641.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 760.95 89 999999999 666.9 812.25 percent of total billed charges DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY 9513999_1 CDM 921 RC 93926 HCPCS outpatient 855 641.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 760.95 89 999999999 666.9 812.25 percent of total billed charges DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY 9513999_1 CDM 921 RC 93926 HCPCS outpatient 855 641.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 769.5 90 999999999 666.9 812.25 percent of total billed charges DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY 9513999_1 CDM 921 RC 93926 HCPCS outpatient 855 641.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 812.25 95 999999999 666.9 812.25 percent of total billed charges DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY 9513999_1 CDM 921 RC 93926 HCPCS outpatient 855 641.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 812.25 95 999999999 666.9 812.25 percent of total billed charges DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY 9513999_1 CDM 921 RC 93926 HCPCS outpatient 855 641.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 760.95 89 999999999 666.9 812.25 percent of total billed charges DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY 9513999_1 CDM 921 RC 93926 HCPCS outpatient 855 641.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 752.4 88 999999999 666.9 812.25 percent of total billed charges DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY 9513999_1 CDM 921 RC 93926 HCPCS outpatient 855 641.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 760.95 89 999999999 666.9 812.25 percent of total billed charges DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY 9514005_1 CDM 921 RC 93931 HCPCS outpatient 1301 975.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1170.9 90 999999999 1014.78 1235.95 percent of total billed charges DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY 9514005_1 CDM 921 RC 93931 HCPCS outpatient 1301 975.75 AETNA MCR ADV AETNA MCR ADV 1014.78 78 999999999 1014.78 1235.95 percent of total billed charges DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY 9514005_1 CDM 921 RC 93931 HCPCS outpatient 1301 975.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1139.29 87.57 999999999 1014.78 1235.95 percent of total billed charges DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY 9514005_1 CDM 921 RC 93931 HCPCS outpatient 1301 975.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 1106.76 85.07 999999999 1014.78 1235.95 percent of total billed charges DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY 9514005_1 CDM 921 RC 93931 HCPCS outpatient 1301 975.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1106.76 85.07 999999999 1014.78 1235.95 percent of total billed charges DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY 9514005_1 CDM 921 RC 93931 HCPCS outpatient 1301 975.75 MOLINA MCAID MOLINA MCAID 1085.03 83.4 999999999 1014.78 1235.95 percent of total billed charges DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY 9514005_1 CDM 921 RC 93931 HCPCS outpatient 1301 975.75 MOLINA MCR ADV MOLINA MCR ADV 1157.89 89 999999999 1014.78 1235.95 percent of total billed charges DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY 9514005_1 CDM 921 RC 93931 HCPCS outpatient 1301 975.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1157.89 89 999999999 1014.78 1235.95 percent of total billed charges DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY 9514005_1 CDM 921 RC 93931 HCPCS outpatient 1301 975.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1157.89 89 999999999 1014.78 1235.95 percent of total billed charges DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY 9514005_1 CDM 921 RC 93931 HCPCS outpatient 1301 975.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1170.9 90 999999999 1014.78 1235.95 percent of total billed charges DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY 9514005_1 CDM 921 RC 93931 HCPCS outpatient 1301 975.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1235.95 95 999999999 1014.78 1235.95 percent of total billed charges DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY 9514005_1 CDM 921 RC 93931 HCPCS outpatient 1301 975.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1235.95 95 999999999 1014.78 1235.95 percent of total billed charges DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY 9514005_1 CDM 921 RC 93931 HCPCS outpatient 1301 975.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1157.89 89 999999999 1014.78 1235.95 percent of total billed charges DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY 9514005_1 CDM 921 RC 93931 HCPCS outpatient 1301 975.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1144.88 88 999999999 1014.78 1235.95 percent of total billed charges DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY 9514005_1 CDM 921 RC 93931 HCPCS outpatient 1301 975.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1157.89 89 999999999 1014.78 1235.95 percent of total billed charges DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; COMPLETE BILATERAL STUDY 9514008_1 CDM 921 RC 93970 HCPCS outpatient 1997 1497.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1797.3 90 999999999 1557.66 1897.15 percent of total billed charges DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; COMPLETE BILATERAL STUDY 9514008_1 CDM 921 RC 93970 HCPCS outpatient 1997 1497.75 AETNA MCR ADV AETNA MCR ADV 1557.66 78 999999999 1557.66 1897.15 percent of total billed charges DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; COMPLETE BILATERAL STUDY 9514008_1 CDM 921 RC 93970 HCPCS outpatient 1997 1497.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1748.77 87.57 999999999 1557.66 1897.15 percent of total billed charges DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; COMPLETE BILATERAL STUDY 9514008_1 CDM 921 RC 93970 HCPCS outpatient 1997 1497.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 1698.85 85.07 999999999 1557.66 1897.15 percent of total billed charges DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; COMPLETE BILATERAL STUDY 9514008_1 CDM 921 RC 93970 HCPCS outpatient 1997 1497.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1698.85 85.07 999999999 1557.66 1897.15 percent of total billed charges DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; COMPLETE BILATERAL STUDY 9514008_1 CDM 921 RC 93970 HCPCS outpatient 1997 1497.75 MOLINA MCAID MOLINA MCAID 1665.5 83.4 999999999 1557.66 1897.15 percent of total billed charges DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; COMPLETE BILATERAL STUDY 9514008_1 CDM 921 RC 93970 HCPCS outpatient 1997 1497.75 MOLINA MCR ADV MOLINA MCR ADV 1777.33 89 999999999 1557.66 1897.15 percent of total billed charges DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; COMPLETE BILATERAL STUDY 9514008_1 CDM 921 RC 93970 HCPCS outpatient 1997 1497.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1777.33 89 999999999 1557.66 1897.15 percent of total billed charges DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; COMPLETE BILATERAL STUDY 9514008_1 CDM 921 RC 93970 HCPCS outpatient 1997 1497.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1777.33 89 999999999 1557.66 1897.15 percent of total billed charges DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; COMPLETE BILATERAL STUDY 9514008_1 CDM 921 RC 93970 HCPCS outpatient 1997 1497.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1797.3 90 999999999 1557.66 1897.15 percent of total billed charges DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; COMPLETE BILATERAL STUDY 9514008_1 CDM 921 RC 93970 HCPCS outpatient 1997 1497.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1897.15 95 999999999 1557.66 1897.15 percent of total billed charges DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; COMPLETE BILATERAL STUDY 9514008_1 CDM 921 RC 93970 HCPCS outpatient 1997 1497.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1897.15 95 999999999 1557.66 1897.15 percent of total billed charges DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; COMPLETE BILATERAL STUDY 9514008_1 CDM 921 RC 93970 HCPCS outpatient 1997 1497.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1777.33 89 999999999 1557.66 1897.15 percent of total billed charges DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; COMPLETE BILATERAL STUDY 9514008_1 CDM 921 RC 93970 HCPCS outpatient 1997 1497.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1757.36 88 999999999 1557.66 1897.15 percent of total billed charges DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; COMPLETE BILATERAL STUDY 9514008_1 CDM 921 RC 93970 HCPCS outpatient 1997 1497.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1777.33 89 999999999 1557.66 1897.15 percent of total billed charges DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; UNILATERAL OR LIMITED STUDY 9514011_1 CDM 921 RC 93971 HCPCS outpatient 1415 1061.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1273.5 90 999999999 1103.7 1344.25 percent of total billed charges DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; UNILATERAL OR LIMITED STUDY 9514011_1 CDM 921 RC 93971 HCPCS outpatient 1415 1061.25 AETNA MCR ADV AETNA MCR ADV 1103.7 78 999999999 1103.7 1344.25 percent of total billed charges DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; UNILATERAL OR LIMITED STUDY 9514011_1 CDM 921 RC 93971 HCPCS outpatient 1415 1061.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1239.12 87.57 999999999 1103.7 1344.25 percent of total billed charges DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; UNILATERAL OR LIMITED STUDY 9514011_1 CDM 921 RC 93971 HCPCS outpatient 1415 1061.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 1203.74 85.07 999999999 1103.7 1344.25 percent of total billed charges DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; UNILATERAL OR LIMITED STUDY 9514011_1 CDM 921 RC 93971 HCPCS outpatient 1415 1061.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1203.74 85.07 999999999 1103.7 1344.25 percent of total billed charges DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; UNILATERAL OR LIMITED STUDY 9514011_1 CDM 921 RC 93971 HCPCS outpatient 1415 1061.25 MOLINA MCAID MOLINA MCAID 1180.11 83.4 999999999 1103.7 1344.25 percent of total billed charges DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; UNILATERAL OR LIMITED STUDY 9514011_1 CDM 921 RC 93971 HCPCS outpatient 1415 1061.25 MOLINA MCR ADV MOLINA MCR ADV 1259.35 89 999999999 1103.7 1344.25 percent of total billed charges DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; UNILATERAL OR LIMITED STUDY 9514011_1 CDM 921 RC 93971 HCPCS outpatient 1415 1061.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1259.35 89 999999999 1103.7 1344.25 percent of total billed charges DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; UNILATERAL OR LIMITED STUDY 9514011_1 CDM 921 RC 93971 HCPCS outpatient 1415 1061.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1259.35 89 999999999 1103.7 1344.25 percent of total billed charges DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; UNILATERAL OR LIMITED STUDY 9514011_1 CDM 921 RC 93971 HCPCS outpatient 1415 1061.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1273.5 90 999999999 1103.7 1344.25 percent of total billed charges DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; UNILATERAL OR LIMITED STUDY 9514011_1 CDM 921 RC 93971 HCPCS outpatient 1415 1061.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1344.25 95 999999999 1103.7 1344.25 percent of total billed charges DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; UNILATERAL OR LIMITED STUDY 9514011_1 CDM 921 RC 93971 HCPCS outpatient 1415 1061.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1344.25 95 999999999 1103.7 1344.25 percent of total billed charges DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; UNILATERAL OR LIMITED STUDY 9514011_1 CDM 921 RC 93971 HCPCS outpatient 1415 1061.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1259.35 89 999999999 1103.7 1344.25 percent of total billed charges DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; UNILATERAL OR LIMITED STUDY 9514011_1 CDM 921 RC 93971 HCPCS outpatient 1415 1061.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1245.2 88 999999999 1103.7 1344.25 percent of total billed charges DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; UNILATERAL OR LIMITED STUDY 9514011_1 CDM 921 RC 93971 HCPCS outpatient 1415 1061.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1259.35 89 999999999 1103.7 1344.25 percent of total billed charges "DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR RETROPERITONEAL ORGANS; COMPLETE STUDY" 9514014_1 CDM 921 RC 93975 HCPCS outpatient 1414 1060.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1272.6 90 999999999 1102.92 1343.3 percent of total billed charges "DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR RETROPERITONEAL ORGANS; COMPLETE STUDY" 9514014_1 CDM 921 RC 93975 HCPCS outpatient 1414 1060.5 AETNA MCR ADV AETNA MCR ADV 1102.92 78 999999999 1102.92 1343.3 percent of total billed charges "DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR RETROPERITONEAL ORGANS; COMPLETE STUDY" 9514014_1 CDM 921 RC 93975 HCPCS outpatient 1414 1060.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1238.24 87.57 999999999 1102.92 1343.3 percent of total billed charges "DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR RETROPERITONEAL ORGANS; COMPLETE STUDY" 9514014_1 CDM 921 RC 93975 HCPCS outpatient 1414 1060.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 1202.89 85.07 999999999 1102.92 1343.3 percent of total billed charges "DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR RETROPERITONEAL ORGANS; COMPLETE STUDY" 9514014_1 CDM 921 RC 93975 HCPCS outpatient 1414 1060.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1202.89 85.07 999999999 1102.92 1343.3 percent of total billed charges "DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR RETROPERITONEAL ORGANS; COMPLETE STUDY" 9514014_1 CDM 921 RC 93975 HCPCS outpatient 1414 1060.5 MOLINA MCAID MOLINA MCAID 1179.28 83.4 999999999 1102.92 1343.3 percent of total billed charges "DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR RETROPERITONEAL ORGANS; COMPLETE STUDY" 9514014_1 CDM 921 RC 93975 HCPCS outpatient 1414 1060.5 MOLINA MCR ADV MOLINA MCR ADV 1258.46 89 999999999 1102.92 1343.3 percent of total billed charges "DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR RETROPERITONEAL ORGANS; COMPLETE STUDY" 9514014_1 CDM 921 RC 93975 HCPCS outpatient 1414 1060.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1258.46 89 999999999 1102.92 1343.3 percent of total billed charges "DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR RETROPERITONEAL ORGANS; COMPLETE STUDY" 9514014_1 CDM 921 RC 93975 HCPCS outpatient 1414 1060.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1258.46 89 999999999 1102.92 1343.3 percent of total billed charges "DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR RETROPERITONEAL ORGANS; COMPLETE STUDY" 9514014_1 CDM 921 RC 93975 HCPCS outpatient 1414 1060.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1272.6 90 999999999 1102.92 1343.3 percent of total billed charges "DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR RETROPERITONEAL ORGANS; COMPLETE STUDY" 9514014_1 CDM 921 RC 93975 HCPCS outpatient 1414 1060.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1343.3 95 999999999 1102.92 1343.3 percent of total billed charges "DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR RETROPERITONEAL ORGANS; COMPLETE STUDY" 9514014_1 CDM 921 RC 93975 HCPCS outpatient 1414 1060.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1343.3 95 999999999 1102.92 1343.3 percent of total billed charges "DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR RETROPERITONEAL ORGANS; COMPLETE STUDY" 9514014_1 CDM 921 RC 93975 HCPCS outpatient 1414 1060.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1258.46 89 999999999 1102.92 1343.3 percent of total billed charges "DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR RETROPERITONEAL ORGANS; COMPLETE STUDY" 9514014_1 CDM 921 RC 93975 HCPCS outpatient 1414 1060.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1244.32 88 999999999 1102.92 1343.3 percent of total billed charges "DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR RETROPERITONEAL ORGANS; COMPLETE STUDY" 9514014_1 CDM 921 RC 93975 HCPCS outpatient 1414 1060.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1258.46 89 999999999 1102.92 1343.3 percent of total billed charges "DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR RETROPERITONEAL ORGANS; LIMITED STUDY" 9514017_1 CDM 921 RC 93976 HCPCS outpatient 856 642 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 770.4 90 999999999 667.68 813.2 percent of total billed charges "DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR RETROPERITONEAL ORGANS; LIMITED STUDY" 9514017_1 CDM 921 RC 93976 HCPCS outpatient 856 642 AETNA MCR ADV AETNA MCR ADV 667.68 78 999999999 667.68 813.2 percent of total billed charges "DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR RETROPERITONEAL ORGANS; LIMITED STUDY" 9514017_1 CDM 921 RC 93976 HCPCS outpatient 856 642 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 749.6 87.57 999999999 667.68 813.2 percent of total billed charges "DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR RETROPERITONEAL ORGANS; LIMITED STUDY" 9514017_1 CDM 921 RC 93976 HCPCS outpatient 856 642 COORDINATED CARE MCAID COORDINATED CARE MCAID 728.2 85.07 999999999 667.68 813.2 percent of total billed charges "DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR RETROPERITONEAL ORGANS; LIMITED STUDY" 9514017_1 CDM 921 RC 93976 HCPCS outpatient 856 642 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 728.2 85.07 999999999 667.68 813.2 percent of total billed charges "DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR RETROPERITONEAL ORGANS; LIMITED STUDY" 9514017_1 CDM 921 RC 93976 HCPCS outpatient 856 642 MOLINA MCAID MOLINA MCAID 713.9 83.4 999999999 667.68 813.2 percent of total billed charges "DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR RETROPERITONEAL ORGANS; LIMITED STUDY" 9514017_1 CDM 921 RC 93976 HCPCS outpatient 856 642 MOLINA MCR ADV MOLINA MCR ADV 761.84 89 999999999 667.68 813.2 percent of total billed charges "DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR RETROPERITONEAL ORGANS; LIMITED STUDY" 9514017_1 CDM 921 RC 93976 HCPCS outpatient 856 642 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 761.84 89 999999999 667.68 813.2 percent of total billed charges "DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR RETROPERITONEAL ORGANS; LIMITED STUDY" 9514017_1 CDM 921 RC 93976 HCPCS outpatient 856 642 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 761.84 89 999999999 667.68 813.2 percent of total billed charges "DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR RETROPERITONEAL ORGANS; LIMITED STUDY" 9514017_1 CDM 921 RC 93976 HCPCS outpatient 856 642 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 770.4 90 999999999 667.68 813.2 percent of total billed charges "DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR RETROPERITONEAL ORGANS; LIMITED STUDY" 9514017_1 CDM 921 RC 93976 HCPCS outpatient 856 642 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 813.2 95 999999999 667.68 813.2 percent of total billed charges "DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR RETROPERITONEAL ORGANS; LIMITED STUDY" 9514017_1 CDM 921 RC 93976 HCPCS outpatient 856 642 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 813.2 95 999999999 667.68 813.2 percent of total billed charges "DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR RETROPERITONEAL ORGANS; LIMITED STUDY" 9514017_1 CDM 921 RC 93976 HCPCS outpatient 856 642 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 761.84 89 999999999 667.68 813.2 percent of total billed charges "DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR RETROPERITONEAL ORGANS; LIMITED STUDY" 9514017_1 CDM 921 RC 93976 HCPCS outpatient 856 642 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 753.28 88 999999999 667.68 813.2 percent of total billed charges "DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR RETROPERITONEAL ORGANS; LIMITED STUDY" 9514017_1 CDM 921 RC 93976 HCPCS outpatient 856 642 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 761.84 89 999999999 667.68 813.2 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 9514086_1 CDM 361 RC 20610 HCPCS outpatient 322 241.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 289.8 999999999 251.16 305.9 case rate "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 9514086_1 CDM 361 RC 20610 HCPCS outpatient 322 241.5 AETNA MCR ADV AETNA MCR ADV 251.16 78 999999999 251.16 305.9 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 9514086_1 CDM 361 RC 20610 HCPCS outpatient 322 241.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 281.98 87.57 999999999 251.16 305.9 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 9514086_1 CDM 361 RC 20610 HCPCS outpatient 322 241.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 273.93 85.07 999999999 251.16 305.9 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 9514086_1 CDM 361 RC 20610 HCPCS outpatient 322 241.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 273.93 85.07 999999999 251.16 305.9 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 9514086_1 CDM 361 RC 20610 HCPCS outpatient 322 241.5 MOLINA MCAID MOLINA MCAID 268.55 83.4 999999999 251.16 305.9 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 9514086_1 CDM 361 RC 20610 HCPCS outpatient 322 241.5 MOLINA MCR ADV MOLINA MCR ADV 286.58 89 999999999 251.16 305.9 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 9514086_1 CDM 361 RC 20610 HCPCS outpatient 322 241.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 286.58 89 999999999 251.16 305.9 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 9514086_1 CDM 361 RC 20610 HCPCS outpatient 322 241.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 286.58 89 999999999 251.16 305.9 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 9514086_1 CDM 361 RC 20610 HCPCS outpatient 322 241.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 289.8 90 999999999 251.16 305.9 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 9514086_1 CDM 361 RC 20610 HCPCS outpatient 322 241.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 305.9 95 999999999 251.16 305.9 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 9514086_1 CDM 361 RC 20610 HCPCS outpatient 322 241.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 305.9 95 999999999 251.16 305.9 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 9514086_1 CDM 361 RC 20610 HCPCS outpatient 322 241.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 286.58 89 999999999 251.16 305.9 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 9514086_1 CDM 361 RC 20610 HCPCS outpatient 322 241.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 283.36 88 999999999 251.16 305.9 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE" 9514086_1 CDM 361 RC 20610 HCPCS outpatient 322 241.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 286.58 89 999999999 251.16 305.9 percent of total billed charges INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER 9514132_1 CDM 361 RC 36556 HCPCS outpatient 3175 2381.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 2857.5 999999999 2476.5 3016.25 case rate INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER 9514132_1 CDM 361 RC 36556 HCPCS outpatient 3175 2381.25 AETNA MCR ADV AETNA MCR ADV 2476.5 78 999999999 2476.5 3016.25 percent of total billed charges INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER 9514132_1 CDM 361 RC 36556 HCPCS outpatient 3175 2381.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 2780.35 87.57 999999999 2476.5 3016.25 percent of total billed charges INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER 9514132_1 CDM 361 RC 36556 HCPCS outpatient 3175 2381.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 2700.97 85.07 999999999 2476.5 3016.25 percent of total billed charges INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER 9514132_1 CDM 361 RC 36556 HCPCS outpatient 3175 2381.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 2700.97 85.07 999999999 2476.5 3016.25 percent of total billed charges INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER 9514132_1 CDM 361 RC 36556 HCPCS outpatient 3175 2381.25 MOLINA MCAID MOLINA MCAID 2647.95 83.4 999999999 2476.5 3016.25 percent of total billed charges INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER 9514132_1 CDM 361 RC 36556 HCPCS outpatient 3175 2381.25 MOLINA MCR ADV MOLINA MCR ADV 2825.75 89 999999999 2476.5 3016.25 percent of total billed charges INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER 9514132_1 CDM 361 RC 36556 HCPCS outpatient 3175 2381.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 2825.75 89 999999999 2476.5 3016.25 percent of total billed charges INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER 9514132_1 CDM 361 RC 36556 HCPCS outpatient 3175 2381.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 2825.75 89 999999999 2476.5 3016.25 percent of total billed charges INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER 9514132_1 CDM 361 RC 36556 HCPCS outpatient 3175 2381.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 2857.5 90 999999999 2476.5 3016.25 percent of total billed charges INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER 9514132_1 CDM 361 RC 36556 HCPCS outpatient 3175 2381.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 3016.25 95 999999999 2476.5 3016.25 percent of total billed charges INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER 9514132_1 CDM 361 RC 36556 HCPCS outpatient 3175 2381.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 3016.25 95 999999999 2476.5 3016.25 percent of total billed charges INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER 9514132_1 CDM 361 RC 36556 HCPCS outpatient 3175 2381.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 2825.75 89 999999999 2476.5 3016.25 percent of total billed charges INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER 9514132_1 CDM 361 RC 36556 HCPCS outpatient 3175 2381.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 2794 88 999999999 2476.5 3016.25 percent of total billed charges INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER 9514132_1 CDM 361 RC 36556 HCPCS outpatient 3175 2381.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 2825.75 89 999999999 2476.5 3016.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 9514263_1 CDM 361 RC 20605 HCPCS outpatient 695 521.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 625.5 999999999 542.1 660.25 case rate "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 9514263_1 CDM 361 RC 20605 HCPCS outpatient 695 521.25 AETNA MCR ADV AETNA MCR ADV 542.1 78 999999999 542.1 660.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 9514263_1 CDM 361 RC 20605 HCPCS outpatient 695 521.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 608.61 87.57 999999999 542.1 660.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 9514263_1 CDM 361 RC 20605 HCPCS outpatient 695 521.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 591.24 85.07 999999999 542.1 660.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 9514263_1 CDM 361 RC 20605 HCPCS outpatient 695 521.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 591.24 85.07 999999999 542.1 660.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 9514263_1 CDM 361 RC 20605 HCPCS outpatient 695 521.25 MOLINA MCAID MOLINA MCAID 579.63 83.4 999999999 542.1 660.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 9514263_1 CDM 361 RC 20605 HCPCS outpatient 695 521.25 MOLINA MCR ADV MOLINA MCR ADV 618.55 89 999999999 542.1 660.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 9514263_1 CDM 361 RC 20605 HCPCS outpatient 695 521.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 618.55 89 999999999 542.1 660.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 9514263_1 CDM 361 RC 20605 HCPCS outpatient 695 521.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 618.55 89 999999999 542.1 660.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 9514263_1 CDM 361 RC 20605 HCPCS outpatient 695 521.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 625.5 90 999999999 542.1 660.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 9514263_1 CDM 361 RC 20605 HCPCS outpatient 695 521.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 660.25 95 999999999 542.1 660.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 9514263_1 CDM 361 RC 20605 HCPCS outpatient 695 521.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 660.25 95 999999999 542.1 660.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 9514263_1 CDM 361 RC 20605 HCPCS outpatient 695 521.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 618.55 89 999999999 542.1 660.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 9514263_1 CDM 361 RC 20605 HCPCS outpatient 695 521.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 611.6 88 999999999 542.1 660.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE" 9514263_1 CDM 361 RC 20605 HCPCS outpatient 695 521.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 618.55 89 999999999 542.1 660.25 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 9514274_1 CDM 361 RC 64400 HCPCS outpatient 730 547.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 657 999999999 569.4 693.5 case rate "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 9514274_1 CDM 361 RC 64400 HCPCS outpatient 730 547.5 AETNA MCR ADV AETNA MCR ADV 569.4 78 999999999 569.4 693.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 9514274_1 CDM 361 RC 64400 HCPCS outpatient 730 547.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 639.26 87.57 999999999 569.4 693.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 9514274_1 CDM 361 RC 64400 HCPCS outpatient 730 547.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 621.01 85.07 999999999 569.4 693.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 9514274_1 CDM 361 RC 64400 HCPCS outpatient 730 547.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 621.01 85.07 999999999 569.4 693.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 9514274_1 CDM 361 RC 64400 HCPCS outpatient 730 547.5 MOLINA MCAID MOLINA MCAID 608.82 83.4 999999999 569.4 693.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 9514274_1 CDM 361 RC 64400 HCPCS outpatient 730 547.5 MOLINA MCR ADV MOLINA MCR ADV 649.7 89 999999999 569.4 693.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 9514274_1 CDM 361 RC 64400 HCPCS outpatient 730 547.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 649.7 89 999999999 569.4 693.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 9514274_1 CDM 361 RC 64400 HCPCS outpatient 730 547.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 649.7 89 999999999 569.4 693.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 9514274_1 CDM 361 RC 64400 HCPCS outpatient 730 547.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 657 90 999999999 569.4 693.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 9514274_1 CDM 361 RC 64400 HCPCS outpatient 730 547.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 693.5 95 999999999 569.4 693.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 9514274_1 CDM 361 RC 64400 HCPCS outpatient 730 547.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 693.5 95 999999999 569.4 693.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 9514274_1 CDM 361 RC 64400 HCPCS outpatient 730 547.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 649.7 89 999999999 569.4 693.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 9514274_1 CDM 361 RC 64400 HCPCS outpatient 730 547.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 642.4 88 999999999 569.4 693.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 9514274_1 CDM 361 RC 64400 HCPCS outpatient 730 547.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 649.7 89 999999999 569.4 693.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 9514274_2 CDM 361 RC 64400 HCPCS outpatient 730 547.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 657 999999999 569.4 693.5 case rate "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 9514274_2 CDM 361 RC 64400 HCPCS outpatient 730 547.5 AETNA MCR ADV AETNA MCR ADV 569.4 78 999999999 569.4 693.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 9514274_2 CDM 361 RC 64400 HCPCS outpatient 730 547.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 639.26 87.57 999999999 569.4 693.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 9514274_2 CDM 361 RC 64400 HCPCS outpatient 730 547.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 621.01 85.07 999999999 569.4 693.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 9514274_2 CDM 361 RC 64400 HCPCS outpatient 730 547.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 621.01 85.07 999999999 569.4 693.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 9514274_2 CDM 361 RC 64400 HCPCS outpatient 730 547.5 MOLINA MCAID MOLINA MCAID 608.82 83.4 999999999 569.4 693.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 9514274_2 CDM 361 RC 64400 HCPCS outpatient 730 547.5 MOLINA MCR ADV MOLINA MCR ADV 649.7 89 999999999 569.4 693.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 9514274_2 CDM 361 RC 64400 HCPCS outpatient 730 547.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 649.7 89 999999999 569.4 693.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 9514274_2 CDM 361 RC 64400 HCPCS outpatient 730 547.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 649.7 89 999999999 569.4 693.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 9514274_2 CDM 361 RC 64400 HCPCS outpatient 730 547.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 657 90 999999999 569.4 693.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 9514274_2 CDM 361 RC 64400 HCPCS outpatient 730 547.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 693.5 95 999999999 569.4 693.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 9514274_2 CDM 361 RC 64400 HCPCS outpatient 730 547.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 693.5 95 999999999 569.4 693.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 9514274_2 CDM 361 RC 64400 HCPCS outpatient 730 547.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 649.7 89 999999999 569.4 693.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 9514274_2 CDM 361 RC 64400 HCPCS outpatient 730 547.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 642.4 88 999999999 569.4 693.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)" 9514274_2 CDM 361 RC 64400 HCPCS outpatient 730 547.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 649.7 89 999999999 569.4 693.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 9514275_1 CDM 361 RC 64450 HCPCS outpatient 679 509.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 611.1 999999999 529.62 645.05 case rate "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 9514275_1 CDM 361 RC 64450 HCPCS outpatient 679 509.25 AETNA MCR ADV AETNA MCR ADV 529.62 78 999999999 529.62 645.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 9514275_1 CDM 361 RC 64450 HCPCS outpatient 679 509.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 594.6 87.57 999999999 529.62 645.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 9514275_1 CDM 361 RC 64450 HCPCS outpatient 679 509.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 577.63 85.07 999999999 529.62 645.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 9514275_1 CDM 361 RC 64450 HCPCS outpatient 679 509.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 577.63 85.07 999999999 529.62 645.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 9514275_1 CDM 361 RC 64450 HCPCS outpatient 679 509.25 MOLINA MCAID MOLINA MCAID 566.29 83.4 999999999 529.62 645.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 9514275_1 CDM 361 RC 64450 HCPCS outpatient 679 509.25 MOLINA MCR ADV MOLINA MCR ADV 604.31 89 999999999 529.62 645.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 9514275_1 CDM 361 RC 64450 HCPCS outpatient 679 509.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 604.31 89 999999999 529.62 645.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 9514275_1 CDM 361 RC 64450 HCPCS outpatient 679 509.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 604.31 89 999999999 529.62 645.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 9514275_1 CDM 361 RC 64450 HCPCS outpatient 679 509.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 611.1 90 999999999 529.62 645.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 9514275_1 CDM 361 RC 64450 HCPCS outpatient 679 509.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 645.05 95 999999999 529.62 645.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 9514275_1 CDM 361 RC 64450 HCPCS outpatient 679 509.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 645.05 95 999999999 529.62 645.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 9514275_1 CDM 361 RC 64450 HCPCS outpatient 679 509.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 604.31 89 999999999 529.62 645.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 9514275_1 CDM 361 RC 64450 HCPCS outpatient 679 509.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 597.52 88 999999999 529.62 645.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 9514275_1 CDM 361 RC 64450 HCPCS outpatient 679 509.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 604.31 89 999999999 529.62 645.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 9514275_2 CDM 361 RC 64450 HCPCS outpatient 924 693 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 831.6 999999999 720.72 877.8 case rate "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 9514275_2 CDM 361 RC 64450 HCPCS outpatient 924 693 AETNA MCR ADV AETNA MCR ADV 720.72 78 999999999 720.72 877.8 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 9514275_2 CDM 361 RC 64450 HCPCS outpatient 924 693 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 809.15 87.57 999999999 720.72 877.8 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 9514275_2 CDM 361 RC 64450 HCPCS outpatient 924 693 COORDINATED CARE MCAID COORDINATED CARE MCAID 786.05 85.07 999999999 720.72 877.8 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 9514275_2 CDM 361 RC 64450 HCPCS outpatient 924 693 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 786.05 85.07 999999999 720.72 877.8 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 9514275_2 CDM 361 RC 64450 HCPCS outpatient 924 693 MOLINA MCAID MOLINA MCAID 770.62 83.4 999999999 720.72 877.8 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 9514275_2 CDM 361 RC 64450 HCPCS outpatient 924 693 MOLINA MCR ADV MOLINA MCR ADV 822.36 89 999999999 720.72 877.8 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 9514275_2 CDM 361 RC 64450 HCPCS outpatient 924 693 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 822.36 89 999999999 720.72 877.8 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 9514275_2 CDM 361 RC 64450 HCPCS outpatient 924 693 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 822.36 89 999999999 720.72 877.8 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 9514275_2 CDM 361 RC 64450 HCPCS outpatient 924 693 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 831.6 90 999999999 720.72 877.8 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 9514275_2 CDM 361 RC 64450 HCPCS outpatient 924 693 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 877.8 95 999999999 720.72 877.8 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 9514275_2 CDM 361 RC 64450 HCPCS outpatient 924 693 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 877.8 95 999999999 720.72 877.8 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 9514275_2 CDM 361 RC 64450 HCPCS outpatient 924 693 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 822.36 89 999999999 720.72 877.8 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 9514275_2 CDM 361 RC 64450 HCPCS outpatient 924 693 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 813.12 88 999999999 720.72 877.8 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH" 9514275_2 CDM 361 RC 64450 HCPCS outpatient 924 693 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 822.36 89 999999999 720.72 877.8 percent of total billed charges "NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS" 9514487_1 CDM 761 RC 97605 HCPCS outpatient 282 211.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 253.8 90 999999999 219.96 267.9 percent of total billed charges "NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS" 9514487_1 CDM 761 RC 97605 HCPCS outpatient 282 211.5 AETNA MCR ADV AETNA MCR ADV 219.96 78 999999999 219.96 267.9 percent of total billed charges "NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS" 9514487_1 CDM 761 RC 97605 HCPCS outpatient 282 211.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 246.95 87.57 999999999 219.96 267.9 percent of total billed charges "NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS" 9514487_1 CDM 761 RC 97605 HCPCS outpatient 282 211.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 239.9 85.07 999999999 219.96 267.9 percent of total billed charges "NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS" 9514487_1 CDM 761 RC 97605 HCPCS outpatient 282 211.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 239.9 85.07 999999999 219.96 267.9 percent of total billed charges "NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS" 9514487_1 CDM 761 RC 97605 HCPCS outpatient 282 211.5 MOLINA MCAID MOLINA MCAID 235.19 83.4 999999999 219.96 267.9 percent of total billed charges "NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS" 9514487_1 CDM 761 RC 97605 HCPCS outpatient 282 211.5 MOLINA MCR ADV MOLINA MCR ADV 250.98 89 999999999 219.96 267.9 percent of total billed charges "NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS" 9514487_1 CDM 761 RC 97605 HCPCS outpatient 282 211.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 250.98 89 999999999 219.96 267.9 percent of total billed charges "NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS" 9514487_1 CDM 761 RC 97605 HCPCS outpatient 282 211.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 250.98 89 999999999 219.96 267.9 percent of total billed charges "NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS" 9514487_1 CDM 761 RC 97605 HCPCS outpatient 282 211.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 253.8 90 999999999 219.96 267.9 percent of total billed charges "NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS" 9514487_1 CDM 761 RC 97605 HCPCS outpatient 282 211.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 267.9 95 999999999 219.96 267.9 percent of total billed charges "NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS" 9514487_1 CDM 761 RC 97605 HCPCS outpatient 282 211.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 267.9 95 999999999 219.96 267.9 percent of total billed charges "NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS" 9514487_1 CDM 761 RC 97605 HCPCS outpatient 282 211.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 250.98 89 999999999 219.96 267.9 percent of total billed charges "NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS" 9514487_1 CDM 761 RC 97605 HCPCS outpatient 282 211.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 248.16 88 999999999 219.96 267.9 percent of total billed charges "NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS" 9514487_1 CDM 761 RC 97605 HCPCS outpatient 282 211.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 250.98 89 999999999 219.96 267.9 percent of total billed charges "NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS" 9514487_2 CDM 761 RC 97605 HCPCS outpatient 282 211.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 253.8 90 999999999 219.96 267.9 percent of total billed charges "NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS" 9514487_2 CDM 761 RC 97605 HCPCS outpatient 282 211.5 AETNA MCR ADV AETNA MCR ADV 219.96 78 999999999 219.96 267.9 percent of total billed charges "NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS" 9514487_2 CDM 761 RC 97605 HCPCS outpatient 282 211.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 246.95 87.57 999999999 219.96 267.9 percent of total billed charges "NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS" 9514487_2 CDM 761 RC 97605 HCPCS outpatient 282 211.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 239.9 85.07 999999999 219.96 267.9 percent of total billed charges "NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS" 9514487_2 CDM 761 RC 97605 HCPCS outpatient 282 211.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 239.9 85.07 999999999 219.96 267.9 percent of total billed charges "NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS" 9514487_2 CDM 761 RC 97605 HCPCS outpatient 282 211.5 MOLINA MCAID MOLINA MCAID 235.19 83.4 999999999 219.96 267.9 percent of total billed charges "NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS" 9514487_2 CDM 761 RC 97605 HCPCS outpatient 282 211.5 MOLINA MCR ADV MOLINA MCR ADV 250.98 89 999999999 219.96 267.9 percent of total billed charges "NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS" 9514487_2 CDM 761 RC 97605 HCPCS outpatient 282 211.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 250.98 89 999999999 219.96 267.9 percent of total billed charges "NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS" 9514487_2 CDM 761 RC 97605 HCPCS outpatient 282 211.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 250.98 89 999999999 219.96 267.9 percent of total billed charges "NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS" 9514487_2 CDM 761 RC 97605 HCPCS outpatient 282 211.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 253.8 90 999999999 219.96 267.9 percent of total billed charges "NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS" 9514487_2 CDM 761 RC 97605 HCPCS outpatient 282 211.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 267.9 95 999999999 219.96 267.9 percent of total billed charges "NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS" 9514487_2 CDM 761 RC 97605 HCPCS outpatient 282 211.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 267.9 95 999999999 219.96 267.9 percent of total billed charges "NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS" 9514487_2 CDM 761 RC 97605 HCPCS outpatient 282 211.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 250.98 89 999999999 219.96 267.9 percent of total billed charges "NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS" 9514487_2 CDM 761 RC 97605 HCPCS outpatient 282 211.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 248.16 88 999999999 219.96 267.9 percent of total billed charges "NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS" 9514487_2 CDM 761 RC 97605 HCPCS outpatient 282 211.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 250.98 89 999999999 219.96 267.9 percent of total billed charges "ACOUSTIC IMMITTANCE TESTING, INCLUDES TYMPANOMETRY (IMPEDANCE TESTING), ACOUSTIC REFLEX THRESHOLD TESTING, AND ACOUSTIC REFLEX DECAY TESTING" 9514512_1 CDM 471 RC 92570 HCPCS outpatient 228 171 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 205.2 90 999999999 177.84 216.6 percent of total billed charges "ACOUSTIC IMMITTANCE TESTING, INCLUDES TYMPANOMETRY (IMPEDANCE TESTING), ACOUSTIC REFLEX THRESHOLD TESTING, AND ACOUSTIC REFLEX DECAY TESTING" 9514512_1 CDM 471 RC 92570 HCPCS outpatient 228 171 AETNA MCR ADV AETNA MCR ADV 177.84 78 999999999 177.84 216.6 percent of total billed charges "ACOUSTIC IMMITTANCE TESTING, INCLUDES TYMPANOMETRY (IMPEDANCE TESTING), ACOUSTIC REFLEX THRESHOLD TESTING, AND ACOUSTIC REFLEX DECAY TESTING" 9514512_1 CDM 471 RC 92570 HCPCS outpatient 228 171 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 199.66 87.57 999999999 177.84 216.6 percent of total billed charges "ACOUSTIC IMMITTANCE TESTING, INCLUDES TYMPANOMETRY (IMPEDANCE TESTING), ACOUSTIC REFLEX THRESHOLD TESTING, AND ACOUSTIC REFLEX DECAY TESTING" 9514512_1 CDM 471 RC 92570 HCPCS outpatient 228 171 COORDINATED CARE MCAID COORDINATED CARE MCAID 193.96 85.07 999999999 177.84 216.6 percent of total billed charges "ACOUSTIC IMMITTANCE TESTING, INCLUDES TYMPANOMETRY (IMPEDANCE TESTING), ACOUSTIC REFLEX THRESHOLD TESTING, AND ACOUSTIC REFLEX DECAY TESTING" 9514512_1 CDM 471 RC 92570 HCPCS outpatient 228 171 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 193.96 85.07 999999999 177.84 216.6 percent of total billed charges "ACOUSTIC IMMITTANCE TESTING, INCLUDES TYMPANOMETRY (IMPEDANCE TESTING), ACOUSTIC REFLEX THRESHOLD TESTING, AND ACOUSTIC REFLEX DECAY TESTING" 9514512_1 CDM 471 RC 92570 HCPCS outpatient 228 171 MOLINA MCAID MOLINA MCAID 190.15 83.4 999999999 177.84 216.6 percent of total billed charges "ACOUSTIC IMMITTANCE TESTING, INCLUDES TYMPANOMETRY (IMPEDANCE TESTING), ACOUSTIC REFLEX THRESHOLD TESTING, AND ACOUSTIC REFLEX DECAY TESTING" 9514512_1 CDM 471 RC 92570 HCPCS outpatient 228 171 MOLINA MCR ADV MOLINA MCR ADV 202.92 89 999999999 177.84 216.6 percent of total billed charges "ACOUSTIC IMMITTANCE TESTING, INCLUDES TYMPANOMETRY (IMPEDANCE TESTING), ACOUSTIC REFLEX THRESHOLD TESTING, AND ACOUSTIC REFLEX DECAY TESTING" 9514512_1 CDM 471 RC 92570 HCPCS outpatient 228 171 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 202.92 89 999999999 177.84 216.6 percent of total billed charges "ACOUSTIC IMMITTANCE TESTING, INCLUDES TYMPANOMETRY (IMPEDANCE TESTING), ACOUSTIC REFLEX THRESHOLD TESTING, AND ACOUSTIC REFLEX DECAY TESTING" 9514512_1 CDM 471 RC 92570 HCPCS outpatient 228 171 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 202.92 89 999999999 177.84 216.6 percent of total billed charges "ACOUSTIC IMMITTANCE TESTING, INCLUDES TYMPANOMETRY (IMPEDANCE TESTING), ACOUSTIC REFLEX THRESHOLD TESTING, AND ACOUSTIC REFLEX DECAY TESTING" 9514512_1 CDM 471 RC 92570 HCPCS outpatient 228 171 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 205.2 90 999999999 177.84 216.6 percent of total billed charges "ACOUSTIC IMMITTANCE TESTING, INCLUDES TYMPANOMETRY (IMPEDANCE TESTING), ACOUSTIC REFLEX THRESHOLD TESTING, AND ACOUSTIC REFLEX DECAY TESTING" 9514512_1 CDM 471 RC 92570 HCPCS outpatient 228 171 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 216.6 95 999999999 177.84 216.6 percent of total billed charges "ACOUSTIC IMMITTANCE TESTING, INCLUDES TYMPANOMETRY (IMPEDANCE TESTING), ACOUSTIC REFLEX THRESHOLD TESTING, AND ACOUSTIC REFLEX DECAY TESTING" 9514512_1 CDM 471 RC 92570 HCPCS outpatient 228 171 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 216.6 95 999999999 177.84 216.6 percent of total billed charges "ACOUSTIC IMMITTANCE TESTING, INCLUDES TYMPANOMETRY (IMPEDANCE TESTING), ACOUSTIC REFLEX THRESHOLD TESTING, AND ACOUSTIC REFLEX DECAY TESTING" 9514512_1 CDM 471 RC 92570 HCPCS outpatient 228 171 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 202.92 89 999999999 177.84 216.6 percent of total billed charges "ACOUSTIC IMMITTANCE TESTING, INCLUDES TYMPANOMETRY (IMPEDANCE TESTING), ACOUSTIC REFLEX THRESHOLD TESTING, AND ACOUSTIC REFLEX DECAY TESTING" 9514512_1 CDM 471 RC 92570 HCPCS outpatient 228 171 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 200.64 88 999999999 177.84 216.6 percent of total billed charges "ACOUSTIC IMMITTANCE TESTING, INCLUDES TYMPANOMETRY (IMPEDANCE TESTING), ACOUSTIC REFLEX THRESHOLD TESTING, AND ACOUSTIC REFLEX DECAY TESTING" 9514512_1 CDM 471 RC 92570 HCPCS outpatient 228 171 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 202.92 89 999999999 177.84 216.6 percent of total billed charges "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 9514519_1 CDM 480 RC 92950 HCPCS outpatient 993 744.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 893.7 90 999999999 774.54 943.35 percent of total billed charges "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 9514519_1 CDM 480 RC 92950 HCPCS outpatient 993 744.75 AETNA MCR ADV AETNA MCR ADV 774.54 78 999999999 774.54 943.35 percent of total billed charges "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 9514519_1 CDM 480 RC 92950 HCPCS outpatient 993 744.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 869.57 87.57 999999999 774.54 943.35 percent of total billed charges "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 9514519_1 CDM 480 RC 92950 HCPCS outpatient 993 744.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 844.75 85.07 999999999 774.54 943.35 percent of total billed charges "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 9514519_1 CDM 480 RC 92950 HCPCS outpatient 993 744.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 844.75 85.07 999999999 774.54 943.35 percent of total billed charges "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 9514519_1 CDM 480 RC 92950 HCPCS outpatient 993 744.75 MOLINA MCAID MOLINA MCAID 828.16 83.4 999999999 774.54 943.35 percent of total billed charges "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 9514519_1 CDM 480 RC 92950 HCPCS outpatient 993 744.75 MOLINA MCR ADV MOLINA MCR ADV 883.77 89 999999999 774.54 943.35 percent of total billed charges "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 9514519_1 CDM 480 RC 92950 HCPCS outpatient 993 744.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 883.77 89 999999999 774.54 943.35 percent of total billed charges "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 9514519_1 CDM 480 RC 92950 HCPCS outpatient 993 744.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 883.77 89 999999999 774.54 943.35 percent of total billed charges "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 9514519_1 CDM 480 RC 92950 HCPCS outpatient 993 744.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 893.7 90 999999999 774.54 943.35 percent of total billed charges "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 9514519_1 CDM 480 RC 92950 HCPCS outpatient 993 744.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 943.35 95 999999999 774.54 943.35 percent of total billed charges "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 9514519_1 CDM 480 RC 92950 HCPCS outpatient 993 744.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 943.35 95 999999999 774.54 943.35 percent of total billed charges "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 9514519_1 CDM 480 RC 92950 HCPCS outpatient 993 744.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 883.77 89 999999999 774.54 943.35 percent of total billed charges "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 9514519_1 CDM 480 RC 92950 HCPCS outpatient 993 744.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 873.84 88 999999999 774.54 943.35 percent of total billed charges "CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST)" 9514519_1 CDM 480 RC 92950 HCPCS outpatient 993 744.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 883.77 89 999999999 774.54 943.35 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 9514597_1 CDM 361 RC 20552 HCPCS outpatient 738 553.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 664.2 999999999 575.64 701.1 case rate "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 9514597_1 CDM 361 RC 20552 HCPCS outpatient 738 553.5 AETNA MCR ADV AETNA MCR ADV 575.64 78 999999999 575.64 701.1 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 9514597_1 CDM 361 RC 20552 HCPCS outpatient 738 553.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 646.27 87.57 999999999 575.64 701.1 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 9514597_1 CDM 361 RC 20552 HCPCS outpatient 738 553.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 627.82 85.07 999999999 575.64 701.1 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 9514597_1 CDM 361 RC 20552 HCPCS outpatient 738 553.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 627.82 85.07 999999999 575.64 701.1 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 9514597_1 CDM 361 RC 20552 HCPCS outpatient 738 553.5 MOLINA MCAID MOLINA MCAID 615.49 83.4 999999999 575.64 701.1 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 9514597_1 CDM 361 RC 20552 HCPCS outpatient 738 553.5 MOLINA MCR ADV MOLINA MCR ADV 656.82 89 999999999 575.64 701.1 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 9514597_1 CDM 361 RC 20552 HCPCS outpatient 738 553.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 656.82 89 999999999 575.64 701.1 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 9514597_1 CDM 361 RC 20552 HCPCS outpatient 738 553.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 656.82 89 999999999 575.64 701.1 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 9514597_1 CDM 361 RC 20552 HCPCS outpatient 738 553.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 664.2 90 999999999 575.64 701.1 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 9514597_1 CDM 361 RC 20552 HCPCS outpatient 738 553.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 701.1 95 999999999 575.64 701.1 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 9514597_1 CDM 361 RC 20552 HCPCS outpatient 738 553.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 701.1 95 999999999 575.64 701.1 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 9514597_1 CDM 361 RC 20552 HCPCS outpatient 738 553.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 656.82 89 999999999 575.64 701.1 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 9514597_1 CDM 361 RC 20552 HCPCS outpatient 738 553.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 649.44 88 999999999 575.64 701.1 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 9514597_1 CDM 361 RC 20552 HCPCS outpatient 738 553.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 656.82 89 999999999 575.64 701.1 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 9514597_50_1 CDM 361 RC 20552 HCPCS outpatient 937 702.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 843.3 999999999 730.86 890.15 case rate "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 9514597_50_1 CDM 361 RC 20552 HCPCS outpatient 937 702.75 AETNA MCR ADV AETNA MCR ADV 50 730.86 78 999999999 730.86 890.15 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 9514597_50_1 CDM 361 RC 20552 HCPCS outpatient 937 702.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 820.53 87.57 999999999 730.86 890.15 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 9514597_50_1 CDM 361 RC 20552 HCPCS outpatient 937 702.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 797.11 85.07 999999999 730.86 890.15 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 9514597_50_1 CDM 361 RC 20552 HCPCS outpatient 937 702.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 797.11 85.07 999999999 730.86 890.15 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 9514597_50_1 CDM 361 RC 20552 HCPCS outpatient 937 702.75 MOLINA MCAID MOLINA MCAID 50 781.46 83.4 999999999 730.86 890.15 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 9514597_50_1 CDM 361 RC 20552 HCPCS outpatient 937 702.75 MOLINA MCR ADV MOLINA MCR ADV 50 833.93 89 999999999 730.86 890.15 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 9514597_50_1 CDM 361 RC 20552 HCPCS outpatient 937 702.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 833.93 89 999999999 730.86 890.15 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 9514597_50_1 CDM 361 RC 20552 HCPCS outpatient 937 702.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 833.93 89 999999999 730.86 890.15 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 9514597_50_1 CDM 361 RC 20552 HCPCS outpatient 937 702.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 843.3 90 999999999 730.86 890.15 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 9514597_50_1 CDM 361 RC 20552 HCPCS outpatient 937 702.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 890.15 95 999999999 730.86 890.15 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 9514597_50_1 CDM 361 RC 20552 HCPCS outpatient 937 702.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 890.15 95 999999999 730.86 890.15 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 9514597_50_1 CDM 361 RC 20552 HCPCS outpatient 937 702.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 833.93 89 999999999 730.86 890.15 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 9514597_50_1 CDM 361 RC 20552 HCPCS outpatient 937 702.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 824.56 88 999999999 730.86 890.15 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)" 9514597_50_1 CDM 361 RC 20552 HCPCS outpatient 937 702.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 833.93 89 999999999 730.86 890.15 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 9514598_1 CDM 361 RC 20553 HCPCS outpatient 750 562.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 675 999999999 585 712.5 case rate "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 9514598_1 CDM 361 RC 20553 HCPCS outpatient 750 562.5 AETNA MCR ADV AETNA MCR ADV 585 78 999999999 585 712.5 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 9514598_1 CDM 361 RC 20553 HCPCS outpatient 750 562.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 656.78 87.57 999999999 585 712.5 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 9514598_1 CDM 361 RC 20553 HCPCS outpatient 750 562.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 638.03 85.07 999999999 585 712.5 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 9514598_1 CDM 361 RC 20553 HCPCS outpatient 750 562.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 638.03 85.07 999999999 585 712.5 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 9514598_1 CDM 361 RC 20553 HCPCS outpatient 750 562.5 MOLINA MCAID MOLINA MCAID 625.5 83.4 999999999 585 712.5 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 9514598_1 CDM 361 RC 20553 HCPCS outpatient 750 562.5 MOLINA MCR ADV MOLINA MCR ADV 667.5 89 999999999 585 712.5 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 9514598_1 CDM 361 RC 20553 HCPCS outpatient 750 562.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 667.5 89 999999999 585 712.5 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 9514598_1 CDM 361 RC 20553 HCPCS outpatient 750 562.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 667.5 89 999999999 585 712.5 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 9514598_1 CDM 361 RC 20553 HCPCS outpatient 750 562.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 675 90 999999999 585 712.5 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 9514598_1 CDM 361 RC 20553 HCPCS outpatient 750 562.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 712.5 95 999999999 585 712.5 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 9514598_1 CDM 361 RC 20553 HCPCS outpatient 750 562.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 712.5 95 999999999 585 712.5 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 9514598_1 CDM 361 RC 20553 HCPCS outpatient 750 562.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 667.5 89 999999999 585 712.5 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 9514598_1 CDM 361 RC 20553 HCPCS outpatient 750 562.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 660 88 999999999 585 712.5 percent of total billed charges "INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES" 9514598_1 CDM 361 RC 20553 HCPCS outpatient 750 562.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 667.5 89 999999999 585 712.5 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR EVALUATION OF HILAR AND MEDIASTINAL LYMPHADENOPATHY); WITH CONTRAST MATERIAL(S)" 9514630_1 CDM 610 RC 71551 HCPCS outpatient 2240 1680 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 2016 90 999999999 1747.2 2128 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR EVALUATION OF HILAR AND MEDIASTINAL LYMPHADENOPATHY); WITH CONTRAST MATERIAL(S)" 9514630_1 CDM 610 RC 71551 HCPCS outpatient 2240 1680 AETNA MCR ADV AETNA MCR ADV 1747.2 78 999999999 1747.2 2128 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR EVALUATION OF HILAR AND MEDIASTINAL LYMPHADENOPATHY); WITH CONTRAST MATERIAL(S)" 9514630_1 CDM 610 RC 71551 HCPCS outpatient 2240 1680 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1961.57 87.57 999999999 1747.2 2128 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR EVALUATION OF HILAR AND MEDIASTINAL LYMPHADENOPATHY); WITH CONTRAST MATERIAL(S)" 9514630_1 CDM 610 RC 71551 HCPCS outpatient 2240 1680 COORDINATED CARE MCAID COORDINATED CARE MCAID 1905.57 85.07 999999999 1747.2 2128 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR EVALUATION OF HILAR AND MEDIASTINAL LYMPHADENOPATHY); WITH CONTRAST MATERIAL(S)" 9514630_1 CDM 610 RC 71551 HCPCS outpatient 2240 1680 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1905.57 85.07 999999999 1747.2 2128 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR EVALUATION OF HILAR AND MEDIASTINAL LYMPHADENOPATHY); WITH CONTRAST MATERIAL(S)" 9514630_1 CDM 610 RC 71551 HCPCS outpatient 2240 1680 MOLINA MCAID MOLINA MCAID 1868.16 83.4 999999999 1747.2 2128 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR EVALUATION OF HILAR AND MEDIASTINAL LYMPHADENOPATHY); WITH CONTRAST MATERIAL(S)" 9514630_1 CDM 610 RC 71551 HCPCS outpatient 2240 1680 MOLINA MCR ADV MOLINA MCR ADV 1993.6 89 999999999 1747.2 2128 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR EVALUATION OF HILAR AND MEDIASTINAL LYMPHADENOPATHY); WITH CONTRAST MATERIAL(S)" 9514630_1 CDM 610 RC 71551 HCPCS outpatient 2240 1680 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1993.6 89 999999999 1747.2 2128 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR EVALUATION OF HILAR AND MEDIASTINAL LYMPHADENOPATHY); WITH CONTRAST MATERIAL(S)" 9514630_1 CDM 610 RC 71551 HCPCS outpatient 2240 1680 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1993.6 89 999999999 1747.2 2128 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR EVALUATION OF HILAR AND MEDIASTINAL LYMPHADENOPATHY); WITH CONTRAST MATERIAL(S)" 9514630_1 CDM 610 RC 71551 HCPCS outpatient 2240 1680 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 2016 90 999999999 1747.2 2128 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR EVALUATION OF HILAR AND MEDIASTINAL LYMPHADENOPATHY); WITH CONTRAST MATERIAL(S)" 9514630_1 CDM 610 RC 71551 HCPCS outpatient 2240 1680 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 2128 95 999999999 1747.2 2128 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR EVALUATION OF HILAR AND MEDIASTINAL LYMPHADENOPATHY); WITH CONTRAST MATERIAL(S)" 9514630_1 CDM 610 RC 71551 HCPCS outpatient 2240 1680 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 2128 95 999999999 1747.2 2128 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR EVALUATION OF HILAR AND MEDIASTINAL LYMPHADENOPATHY); WITH CONTRAST MATERIAL(S)" 9514630_1 CDM 610 RC 71551 HCPCS outpatient 2240 1680 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1993.6 89 999999999 1747.2 2128 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR EVALUATION OF HILAR AND MEDIASTINAL LYMPHADENOPATHY); WITH CONTRAST MATERIAL(S)" 9514630_1 CDM 610 RC 71551 HCPCS outpatient 2240 1680 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1971.2 88 999999999 1747.2 2128 percent of total billed charges "MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR EVALUATION OF HILAR AND MEDIASTINAL LYMPHADENOPATHY); WITH CONTRAST MATERIAL(S)" 9514630_1 CDM 610 RC 71551 HCPCS outpatient 2240 1680 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1993.6 89 999999999 1747.2 2128 percent of total billed charges AUDITORY REHABILITATION; PRELINGUAL HEARING LOSS 9514655_1 CDM 440 RC 92630 HCPCS outpatient 388 291 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 349.2 90 999999999 302.64 368.6 percent of total billed charges AUDITORY REHABILITATION; PRELINGUAL HEARING LOSS 9514655_1 CDM 440 RC 92630 HCPCS outpatient 388 291 AETNA MCR ADV AETNA MCR ADV 302.64 78 999999999 302.64 368.6 percent of total billed charges AUDITORY REHABILITATION; PRELINGUAL HEARING LOSS 9514655_1 CDM 440 RC 92630 HCPCS outpatient 388 291 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 339.77 87.57 999999999 302.64 368.6 percent of total billed charges AUDITORY REHABILITATION; PRELINGUAL HEARING LOSS 9514655_1 CDM 440 RC 92630 HCPCS outpatient 388 291 COORDINATED CARE MCAID COORDINATED CARE MCAID 330.07 85.07 999999999 302.64 368.6 percent of total billed charges AUDITORY REHABILITATION; PRELINGUAL HEARING LOSS 9514655_1 CDM 440 RC 92630 HCPCS outpatient 388 291 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 330.07 85.07 999999999 302.64 368.6 percent of total billed charges AUDITORY REHABILITATION; PRELINGUAL HEARING LOSS 9514655_1 CDM 440 RC 92630 HCPCS outpatient 388 291 MOLINA MCAID MOLINA MCAID 323.59 83.4 999999999 302.64 368.6 percent of total billed charges AUDITORY REHABILITATION; PRELINGUAL HEARING LOSS 9514655_1 CDM 440 RC 92630 HCPCS outpatient 388 291 MOLINA MCR ADV MOLINA MCR ADV 345.32 89 999999999 302.64 368.6 percent of total billed charges AUDITORY REHABILITATION; PRELINGUAL HEARING LOSS 9514655_1 CDM 440 RC 92630 HCPCS outpatient 388 291 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 345.32 89 999999999 302.64 368.6 percent of total billed charges AUDITORY REHABILITATION; PRELINGUAL HEARING LOSS 9514655_1 CDM 440 RC 92630 HCPCS outpatient 388 291 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 345.32 89 999999999 302.64 368.6 percent of total billed charges AUDITORY REHABILITATION; PRELINGUAL HEARING LOSS 9514655_1 CDM 440 RC 92630 HCPCS outpatient 388 291 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 349.2 90 999999999 302.64 368.6 percent of total billed charges AUDITORY REHABILITATION; PRELINGUAL HEARING LOSS 9514655_1 CDM 440 RC 92630 HCPCS outpatient 388 291 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 368.6 95 999999999 302.64 368.6 percent of total billed charges AUDITORY REHABILITATION; PRELINGUAL HEARING LOSS 9514655_1 CDM 440 RC 92630 HCPCS outpatient 388 291 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 368.6 95 999999999 302.64 368.6 percent of total billed charges AUDITORY REHABILITATION; PRELINGUAL HEARING LOSS 9514655_1 CDM 440 RC 92630 HCPCS outpatient 388 291 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 345.32 89 999999999 302.64 368.6 percent of total billed charges AUDITORY REHABILITATION; PRELINGUAL HEARING LOSS 9514655_1 CDM 440 RC 92630 HCPCS outpatient 388 291 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 341.44 88 999999999 302.64 368.6 percent of total billed charges AUDITORY REHABILITATION; PRELINGUAL HEARING LOSS 9514655_1 CDM 440 RC 92630 HCPCS outpatient 388 291 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 345.32 89 999999999 302.64 368.6 percent of total billed charges AUDITORY REHABILITATION; POSTLINGUAL HEARING LOSS 9514656_1 CDM 440 RC 92633 HCPCS outpatient 268 201 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 241.2 90 999999999 209.04 254.6 percent of total billed charges AUDITORY REHABILITATION; POSTLINGUAL HEARING LOSS 9514656_1 CDM 440 RC 92633 HCPCS outpatient 268 201 AETNA MCR ADV AETNA MCR ADV 209.04 78 999999999 209.04 254.6 percent of total billed charges AUDITORY REHABILITATION; POSTLINGUAL HEARING LOSS 9514656_1 CDM 440 RC 92633 HCPCS outpatient 268 201 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 234.69 87.57 999999999 209.04 254.6 percent of total billed charges AUDITORY REHABILITATION; POSTLINGUAL HEARING LOSS 9514656_1 CDM 440 RC 92633 HCPCS outpatient 268 201 COORDINATED CARE MCAID COORDINATED CARE MCAID 227.99 85.07 999999999 209.04 254.6 percent of total billed charges AUDITORY REHABILITATION; POSTLINGUAL HEARING LOSS 9514656_1 CDM 440 RC 92633 HCPCS outpatient 268 201 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 227.99 85.07 999999999 209.04 254.6 percent of total billed charges AUDITORY REHABILITATION; POSTLINGUAL HEARING LOSS 9514656_1 CDM 440 RC 92633 HCPCS outpatient 268 201 MOLINA MCAID MOLINA MCAID 223.51 83.4 999999999 209.04 254.6 percent of total billed charges AUDITORY REHABILITATION; POSTLINGUAL HEARING LOSS 9514656_1 CDM 440 RC 92633 HCPCS outpatient 268 201 MOLINA MCR ADV MOLINA MCR ADV 238.52 89 999999999 209.04 254.6 percent of total billed charges AUDITORY REHABILITATION; POSTLINGUAL HEARING LOSS 9514656_1 CDM 440 RC 92633 HCPCS outpatient 268 201 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 238.52 89 999999999 209.04 254.6 percent of total billed charges AUDITORY REHABILITATION; POSTLINGUAL HEARING LOSS 9514656_1 CDM 440 RC 92633 HCPCS outpatient 268 201 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 238.52 89 999999999 209.04 254.6 percent of total billed charges AUDITORY REHABILITATION; POSTLINGUAL HEARING LOSS 9514656_1 CDM 440 RC 92633 HCPCS outpatient 268 201 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 241.2 90 999999999 209.04 254.6 percent of total billed charges AUDITORY REHABILITATION; POSTLINGUAL HEARING LOSS 9514656_1 CDM 440 RC 92633 HCPCS outpatient 268 201 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 254.6 95 999999999 209.04 254.6 percent of total billed charges AUDITORY REHABILITATION; POSTLINGUAL HEARING LOSS 9514656_1 CDM 440 RC 92633 HCPCS outpatient 268 201 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 254.6 95 999999999 209.04 254.6 percent of total billed charges AUDITORY REHABILITATION; POSTLINGUAL HEARING LOSS 9514656_1 CDM 440 RC 92633 HCPCS outpatient 268 201 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 238.52 89 999999999 209.04 254.6 percent of total billed charges AUDITORY REHABILITATION; POSTLINGUAL HEARING LOSS 9514656_1 CDM 440 RC 92633 HCPCS outpatient 268 201 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 235.84 88 999999999 209.04 254.6 percent of total billed charges AUDITORY REHABILITATION; POSTLINGUAL HEARING LOSS 9514656_1 CDM 440 RC 92633 HCPCS outpatient 268 201 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 238.52 89 999999999 209.04 254.6 percent of total billed charges "STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG, ROSS INFORMATION PROCESSING ASSESSMENT) PER HOUR OF A QUALIFIED HEALTH CARE PROFESSIONAL'S TIME, BOTH FACE-TO-FACE TIME ADMINISTERING TESTS TO THE PATIENT AND TIME INTERPRETING THESE TEST RESULTS AND PREPARING THE REPORT" 9514657_1 CDM 440 RC 96125 HCPCS outpatient 354 265.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 318.6 90 999999999 276.12 336.3 percent of total billed charges "STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG, ROSS INFORMATION PROCESSING ASSESSMENT) PER HOUR OF A QUALIFIED HEALTH CARE PROFESSIONAL'S TIME, BOTH FACE-TO-FACE TIME ADMINISTERING TESTS TO THE PATIENT AND TIME INTERPRETING THESE TEST RESULTS AND PREPARING THE REPORT" 9514657_1 CDM 440 RC 96125 HCPCS outpatient 354 265.5 AETNA MCR ADV AETNA MCR ADV 276.12 78 999999999 276.12 336.3 percent of total billed charges "STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG, ROSS INFORMATION PROCESSING ASSESSMENT) PER HOUR OF A QUALIFIED HEALTH CARE PROFESSIONAL'S TIME, BOTH FACE-TO-FACE TIME ADMINISTERING TESTS TO THE PATIENT AND TIME INTERPRETING THESE TEST RESULTS AND PREPARING THE REPORT" 9514657_1 CDM 440 RC 96125 HCPCS outpatient 354 265.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 310 87.57 999999999 276.12 336.3 percent of total billed charges "STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG, ROSS INFORMATION PROCESSING ASSESSMENT) PER HOUR OF A QUALIFIED HEALTH CARE PROFESSIONAL'S TIME, BOTH FACE-TO-FACE TIME ADMINISTERING TESTS TO THE PATIENT AND TIME INTERPRETING THESE TEST RESULTS AND PREPARING THE REPORT" 9514657_1 CDM 440 RC 96125 HCPCS outpatient 354 265.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 301.15 85.07 999999999 276.12 336.3 percent of total billed charges "STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG, ROSS INFORMATION PROCESSING ASSESSMENT) PER HOUR OF A QUALIFIED HEALTH CARE PROFESSIONAL'S TIME, BOTH FACE-TO-FACE TIME ADMINISTERING TESTS TO THE PATIENT AND TIME INTERPRETING THESE TEST RESULTS AND PREPARING THE REPORT" 9514657_1 CDM 440 RC 96125 HCPCS outpatient 354 265.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 301.15 85.07 999999999 276.12 336.3 percent of total billed charges "STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG, ROSS INFORMATION PROCESSING ASSESSMENT) PER HOUR OF A QUALIFIED HEALTH CARE PROFESSIONAL'S TIME, BOTH FACE-TO-FACE TIME ADMINISTERING TESTS TO THE PATIENT AND TIME INTERPRETING THESE TEST RESULTS AND PREPARING THE REPORT" 9514657_1 CDM 440 RC 96125 HCPCS outpatient 354 265.5 MOLINA MCAID MOLINA MCAID 295.24 83.4 999999999 276.12 336.3 percent of total billed charges "STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG, ROSS INFORMATION PROCESSING ASSESSMENT) PER HOUR OF A QUALIFIED HEALTH CARE PROFESSIONAL'S TIME, BOTH FACE-TO-FACE TIME ADMINISTERING TESTS TO THE PATIENT AND TIME INTERPRETING THESE TEST RESULTS AND PREPARING THE REPORT" 9514657_1 CDM 440 RC 96125 HCPCS outpatient 354 265.5 MOLINA MCR ADV MOLINA MCR ADV 315.06 89 999999999 276.12 336.3 percent of total billed charges "STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG, ROSS INFORMATION PROCESSING ASSESSMENT) PER HOUR OF A QUALIFIED HEALTH CARE PROFESSIONAL'S TIME, BOTH FACE-TO-FACE TIME ADMINISTERING TESTS TO THE PATIENT AND TIME INTERPRETING THESE TEST RESULTS AND PREPARING THE REPORT" 9514657_1 CDM 440 RC 96125 HCPCS outpatient 354 265.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 315.06 89 999999999 276.12 336.3 percent of total billed charges "STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG, ROSS INFORMATION PROCESSING ASSESSMENT) PER HOUR OF A QUALIFIED HEALTH CARE PROFESSIONAL'S TIME, BOTH FACE-TO-FACE TIME ADMINISTERING TESTS TO THE PATIENT AND TIME INTERPRETING THESE TEST RESULTS AND PREPARING THE REPORT" 9514657_1 CDM 440 RC 96125 HCPCS outpatient 354 265.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 315.06 89 999999999 276.12 336.3 percent of total billed charges "STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG, ROSS INFORMATION PROCESSING ASSESSMENT) PER HOUR OF A QUALIFIED HEALTH CARE PROFESSIONAL'S TIME, BOTH FACE-TO-FACE TIME ADMINISTERING TESTS TO THE PATIENT AND TIME INTERPRETING THESE TEST RESULTS AND PREPARING THE REPORT" 9514657_1 CDM 440 RC 96125 HCPCS outpatient 354 265.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 318.6 90 999999999 276.12 336.3 percent of total billed charges "STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG, ROSS INFORMATION PROCESSING ASSESSMENT) PER HOUR OF A QUALIFIED HEALTH CARE PROFESSIONAL'S TIME, BOTH FACE-TO-FACE TIME ADMINISTERING TESTS TO THE PATIENT AND TIME INTERPRETING THESE TEST RESULTS AND PREPARING THE REPORT" 9514657_1 CDM 440 RC 96125 HCPCS outpatient 354 265.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 336.3 95 999999999 276.12 336.3 percent of total billed charges "STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG, ROSS INFORMATION PROCESSING ASSESSMENT) PER HOUR OF A QUALIFIED HEALTH CARE PROFESSIONAL'S TIME, BOTH FACE-TO-FACE TIME ADMINISTERING TESTS TO THE PATIENT AND TIME INTERPRETING THESE TEST RESULTS AND PREPARING THE REPORT" 9514657_1 CDM 440 RC 96125 HCPCS outpatient 354 265.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 336.3 95 999999999 276.12 336.3 percent of total billed charges "STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG, ROSS INFORMATION PROCESSING ASSESSMENT) PER HOUR OF A QUALIFIED HEALTH CARE PROFESSIONAL'S TIME, BOTH FACE-TO-FACE TIME ADMINISTERING TESTS TO THE PATIENT AND TIME INTERPRETING THESE TEST RESULTS AND PREPARING THE REPORT" 9514657_1 CDM 440 RC 96125 HCPCS outpatient 354 265.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 315.06 89 999999999 276.12 336.3 percent of total billed charges "STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG, ROSS INFORMATION PROCESSING ASSESSMENT) PER HOUR OF A QUALIFIED HEALTH CARE PROFESSIONAL'S TIME, BOTH FACE-TO-FACE TIME ADMINISTERING TESTS TO THE PATIENT AND TIME INTERPRETING THESE TEST RESULTS AND PREPARING THE REPORT" 9514657_1 CDM 440 RC 96125 HCPCS outpatient 354 265.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 311.52 88 999999999 276.12 336.3 percent of total billed charges "STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG, ROSS INFORMATION PROCESSING ASSESSMENT) PER HOUR OF A QUALIFIED HEALTH CARE PROFESSIONAL'S TIME, BOTH FACE-TO-FACE TIME ADMINISTERING TESTS TO THE PATIENT AND TIME INTERPRETING THESE TEST RESULTS AND PREPARING THE REPORT" 9514657_1 CDM 440 RC 96125 HCPCS outpatient 354 265.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 315.06 89 999999999 276.12 336.3 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 9514658_1 CDM 761 RC 51700 HCPCS outpatient 202 151.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 181.8 999999999 157.56 191.9 case rate "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 9514658_1 CDM 761 RC 51700 HCPCS outpatient 202 151.5 AETNA MCR ADV AETNA MCR ADV 157.56 78 999999999 157.56 191.9 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 9514658_1 CDM 761 RC 51700 HCPCS outpatient 202 151.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 176.89 87.57 999999999 157.56 191.9 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 9514658_1 CDM 761 RC 51700 HCPCS outpatient 202 151.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 171.84 85.07 999999999 157.56 191.9 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 9514658_1 CDM 761 RC 51700 HCPCS outpatient 202 151.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 171.84 85.07 999999999 157.56 191.9 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 9514658_1 CDM 761 RC 51700 HCPCS outpatient 202 151.5 MOLINA MCAID MOLINA MCAID 168.47 83.4 999999999 157.56 191.9 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 9514658_1 CDM 761 RC 51700 HCPCS outpatient 202 151.5 MOLINA MCR ADV MOLINA MCR ADV 179.78 89 999999999 157.56 191.9 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 9514658_1 CDM 761 RC 51700 HCPCS outpatient 202 151.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 179.78 89 999999999 157.56 191.9 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 9514658_1 CDM 761 RC 51700 HCPCS outpatient 202 151.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 179.78 89 999999999 157.56 191.9 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 9514658_1 CDM 761 RC 51700 HCPCS outpatient 202 151.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 181.8 90 999999999 157.56 191.9 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 9514658_1 CDM 761 RC 51700 HCPCS outpatient 202 151.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 191.9 95 999999999 157.56 191.9 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 9514658_1 CDM 761 RC 51700 HCPCS outpatient 202 151.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 191.9 95 999999999 157.56 191.9 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 9514658_1 CDM 761 RC 51700 HCPCS outpatient 202 151.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 179.78 89 999999999 157.56 191.9 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 9514658_1 CDM 761 RC 51700 HCPCS outpatient 202 151.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 177.76 88 999999999 157.56 191.9 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 9514658_1 CDM 761 RC 51700 HCPCS outpatient 202 151.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 179.78 89 999999999 157.56 191.9 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 9514658_2 CDM 761 RC 51700 HCPCS outpatient 350 262.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 315 999999999 273 332.5 case rate "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 9514658_2 CDM 761 RC 51700 HCPCS outpatient 350 262.5 AETNA MCR ADV AETNA MCR ADV 273 78 999999999 273 332.5 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 9514658_2 CDM 761 RC 51700 HCPCS outpatient 350 262.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 306.5 87.57 999999999 273 332.5 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 9514658_2 CDM 761 RC 51700 HCPCS outpatient 350 262.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 297.75 85.07 999999999 273 332.5 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 9514658_2 CDM 761 RC 51700 HCPCS outpatient 350 262.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 297.75 85.07 999999999 273 332.5 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 9514658_2 CDM 761 RC 51700 HCPCS outpatient 350 262.5 MOLINA MCAID MOLINA MCAID 291.9 83.4 999999999 273 332.5 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 9514658_2 CDM 761 RC 51700 HCPCS outpatient 350 262.5 MOLINA MCR ADV MOLINA MCR ADV 311.5 89 999999999 273 332.5 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 9514658_2 CDM 761 RC 51700 HCPCS outpatient 350 262.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 311.5 89 999999999 273 332.5 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 9514658_2 CDM 761 RC 51700 HCPCS outpatient 350 262.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 311.5 89 999999999 273 332.5 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 9514658_2 CDM 761 RC 51700 HCPCS outpatient 350 262.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 315 90 999999999 273 332.5 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 9514658_2 CDM 761 RC 51700 HCPCS outpatient 350 262.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 332.5 95 999999999 273 332.5 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 9514658_2 CDM 761 RC 51700 HCPCS outpatient 350 262.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 332.5 95 999999999 273 332.5 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 9514658_2 CDM 761 RC 51700 HCPCS outpatient 350 262.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 311.5 89 999999999 273 332.5 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 9514658_2 CDM 761 RC 51700 HCPCS outpatient 350 262.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 308 88 999999999 273 332.5 percent of total billed charges "BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION" 9514658_2 CDM 761 RC 51700 HCPCS outpatient 350 262.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 311.5 89 999999999 273 332.5 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 9514752_1 CDM 361 RC 10060 HCPCS outpatient 263 197.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 236.7 999999999 205.14 249.85 case rate "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 9514752_1 CDM 361 RC 10060 HCPCS outpatient 263 197.25 AETNA MCR ADV AETNA MCR ADV 205.14 78 999999999 205.14 249.85 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 9514752_1 CDM 361 RC 10060 HCPCS outpatient 263 197.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 230.31 87.57 999999999 205.14 249.85 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 9514752_1 CDM 361 RC 10060 HCPCS outpatient 263 197.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 223.73 85.07 999999999 205.14 249.85 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 9514752_1 CDM 361 RC 10060 HCPCS outpatient 263 197.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 223.73 85.07 999999999 205.14 249.85 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 9514752_1 CDM 361 RC 10060 HCPCS outpatient 263 197.25 MOLINA MCAID MOLINA MCAID 219.34 83.4 999999999 205.14 249.85 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 9514752_1 CDM 361 RC 10060 HCPCS outpatient 263 197.25 MOLINA MCR ADV MOLINA MCR ADV 234.07 89 999999999 205.14 249.85 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 9514752_1 CDM 361 RC 10060 HCPCS outpatient 263 197.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 234.07 89 999999999 205.14 249.85 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 9514752_1 CDM 361 RC 10060 HCPCS outpatient 263 197.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 234.07 89 999999999 205.14 249.85 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 9514752_1 CDM 361 RC 10060 HCPCS outpatient 263 197.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 236.7 90 999999999 205.14 249.85 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 9514752_1 CDM 361 RC 10060 HCPCS outpatient 263 197.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 249.85 95 999999999 205.14 249.85 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 9514752_1 CDM 361 RC 10060 HCPCS outpatient 263 197.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 249.85 95 999999999 205.14 249.85 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 9514752_1 CDM 361 RC 10060 HCPCS outpatient 263 197.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 234.07 89 999999999 205.14 249.85 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 9514752_1 CDM 361 RC 10060 HCPCS outpatient 263 197.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 231.44 88 999999999 205.14 249.85 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE" 9514752_1 CDM 361 RC 10060 HCPCS outpatient 263 197.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 234.07 89 999999999 205.14 249.85 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, SINGLE LEVEL" 9514779_1 CDM 361 RC 64420 HCPCS outpatient 404 303 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 363.6 999999999 315.12 383.8 case rate "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, SINGLE LEVEL" 9514779_1 CDM 361 RC 64420 HCPCS outpatient 404 303 AETNA MCR ADV AETNA MCR ADV 315.12 78 999999999 315.12 383.8 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, SINGLE LEVEL" 9514779_1 CDM 361 RC 64420 HCPCS outpatient 404 303 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 353.78 87.57 999999999 315.12 383.8 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, SINGLE LEVEL" 9514779_1 CDM 361 RC 64420 HCPCS outpatient 404 303 COORDINATED CARE MCAID COORDINATED CARE MCAID 343.68 85.07 999999999 315.12 383.8 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, SINGLE LEVEL" 9514779_1 CDM 361 RC 64420 HCPCS outpatient 404 303 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 343.68 85.07 999999999 315.12 383.8 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, SINGLE LEVEL" 9514779_1 CDM 361 RC 64420 HCPCS outpatient 404 303 MOLINA MCAID MOLINA MCAID 336.94 83.4 999999999 315.12 383.8 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, SINGLE LEVEL" 9514779_1 CDM 361 RC 64420 HCPCS outpatient 404 303 MOLINA MCR ADV MOLINA MCR ADV 359.56 89 999999999 315.12 383.8 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, SINGLE LEVEL" 9514779_1 CDM 361 RC 64420 HCPCS outpatient 404 303 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 359.56 89 999999999 315.12 383.8 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, SINGLE LEVEL" 9514779_1 CDM 361 RC 64420 HCPCS outpatient 404 303 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 359.56 89 999999999 315.12 383.8 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, SINGLE LEVEL" 9514779_1 CDM 361 RC 64420 HCPCS outpatient 404 303 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 363.6 90 999999999 315.12 383.8 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, SINGLE LEVEL" 9514779_1 CDM 361 RC 64420 HCPCS outpatient 404 303 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 383.8 95 999999999 315.12 383.8 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, SINGLE LEVEL" 9514779_1 CDM 361 RC 64420 HCPCS outpatient 404 303 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 383.8 95 999999999 315.12 383.8 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, SINGLE LEVEL" 9514779_1 CDM 361 RC 64420 HCPCS outpatient 404 303 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 359.56 89 999999999 315.12 383.8 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, SINGLE LEVEL" 9514779_1 CDM 361 RC 64420 HCPCS outpatient 404 303 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 355.52 88 999999999 315.12 383.8 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, SINGLE LEVEL" 9514779_1 CDM 361 RC 64420 HCPCS outpatient 404 303 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 359.56 89 999999999 315.12 383.8 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_1 CDM 361 RC 64483 HCPCS outpatient 1586 1189.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1427.4 999999999 1237.08 1506.7 case rate "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_1 CDM 361 RC 64483 HCPCS outpatient 1586 1189.5 AETNA MCR ADV AETNA MCR ADV 1237.08 78 999999999 1237.08 1506.7 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_1 CDM 361 RC 64483 HCPCS outpatient 1586 1189.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1388.86 87.57 999999999 1237.08 1506.7 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_1 CDM 361 RC 64483 HCPCS outpatient 1586 1189.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 1349.21 85.07 999999999 1237.08 1506.7 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_1 CDM 361 RC 64483 HCPCS outpatient 1586 1189.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1349.21 85.07 999999999 1237.08 1506.7 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_1 CDM 361 RC 64483 HCPCS outpatient 1586 1189.5 MOLINA MCAID MOLINA MCAID 1322.72 83.4 999999999 1237.08 1506.7 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_1 CDM 361 RC 64483 HCPCS outpatient 1586 1189.5 MOLINA MCR ADV MOLINA MCR ADV 1411.54 89 999999999 1237.08 1506.7 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_1 CDM 361 RC 64483 HCPCS outpatient 1586 1189.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1411.54 89 999999999 1237.08 1506.7 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_1 CDM 361 RC 64483 HCPCS outpatient 1586 1189.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1411.54 89 999999999 1237.08 1506.7 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_1 CDM 361 RC 64483 HCPCS outpatient 1586 1189.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1427.4 90 999999999 1237.08 1506.7 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_1 CDM 361 RC 64483 HCPCS outpatient 1586 1189.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1506.7 95 999999999 1237.08 1506.7 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_1 CDM 361 RC 64483 HCPCS outpatient 1586 1189.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1506.7 95 999999999 1237.08 1506.7 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_1 CDM 361 RC 64483 HCPCS outpatient 1586 1189.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1411.54 89 999999999 1237.08 1506.7 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_1 CDM 361 RC 64483 HCPCS outpatient 1586 1189.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1395.68 88 999999999 1237.08 1506.7 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_1 CDM 361 RC 64483 HCPCS outpatient 1586 1189.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1411.54 89 999999999 1237.08 1506.7 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_50 CDM 361 RC 64483 HCPCS inpatient 2379 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 999999999 "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_50 CDM 361 RC 64483 HCPCS inpatient 2379 AETNA MCR ADV AETNA MCR ADV 50 999999999 "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_50 CDM 361 RC 64483 HCPCS inpatient 2379 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 999999999 "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_50 CDM 361 RC 64483 HCPCS inpatient 2379 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 999999999 "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_50 CDM 361 RC 64483 HCPCS inpatient 2379 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 999999999 "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_50 CDM 361 RC 64483 HCPCS inpatient 2379 MOLINA MCAID MOLINA MCAID 50 999999999 "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_50 CDM 361 RC 64483 HCPCS inpatient 2379 MOLINA MCR ADV MOLINA MCR ADV 50 999999999 "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_50 CDM 361 RC 64483 HCPCS inpatient 2379 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 999999999 "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_50 CDM 361 RC 64483 HCPCS inpatient 2379 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 999999999 "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_50 CDM 361 RC 64483 HCPCS inpatient 2379 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 999999999 "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_50 CDM 361 RC 64483 HCPCS inpatient 2379 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 999999999 "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_50 CDM 361 RC 64483 HCPCS inpatient 2379 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 999999999 "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_50 CDM 361 RC 64483 HCPCS inpatient 2379 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 999999999 "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_50 CDM 361 RC 64483 HCPCS inpatient 2379 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 999999999 "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_50 CDM 361 RC 64483 HCPCS inpatient 2379 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 999999999 "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_50_1 CDM 361 RC 64483 HCPCS outpatient 2379 1784.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 2141.1 999999999 1855.62 2260.05 case rate "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_50_1 CDM 361 RC 64483 HCPCS outpatient 2379 1784.25 AETNA MCR ADV AETNA MCR ADV 50 1855.62 78 999999999 1855.62 2260.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_50_1 CDM 361 RC 64483 HCPCS outpatient 2379 1784.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 2083.29 87.57 999999999 1855.62 2260.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_50_1 CDM 361 RC 64483 HCPCS outpatient 2379 1784.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 2023.82 85.07 999999999 1855.62 2260.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_50_1 CDM 361 RC 64483 HCPCS outpatient 2379 1784.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 2023.82 85.07 999999999 1855.62 2260.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_50_1 CDM 361 RC 64483 HCPCS outpatient 2379 1784.25 MOLINA MCAID MOLINA MCAID 50 1984.09 83.4 999999999 1855.62 2260.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_50_1 CDM 361 RC 64483 HCPCS outpatient 2379 1784.25 MOLINA MCR ADV MOLINA MCR ADV 50 2117.31 89 999999999 1855.62 2260.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_50_1 CDM 361 RC 64483 HCPCS outpatient 2379 1784.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 2117.31 89 999999999 1855.62 2260.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_50_1 CDM 361 RC 64483 HCPCS outpatient 2379 1784.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 2117.31 89 999999999 1855.62 2260.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_50_1 CDM 361 RC 64483 HCPCS outpatient 2379 1784.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 2141.1 90 999999999 1855.62 2260.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_50_1 CDM 361 RC 64483 HCPCS outpatient 2379 1784.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 2260.05 95 999999999 1855.62 2260.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_50_1 CDM 361 RC 64483 HCPCS outpatient 2379 1784.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 2260.05 95 999999999 1855.62 2260.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_50_1 CDM 361 RC 64483 HCPCS outpatient 2379 1784.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 2117.31 89 999999999 1855.62 2260.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_50_1 CDM 361 RC 64483 HCPCS outpatient 2379 1784.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 2093.52 88 999999999 1855.62 2260.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL" 9514782_50_1 CDM 361 RC 64483 HCPCS outpatient 2379 1784.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 2117.31 89 999999999 1855.62 2260.05 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9514783_1 CDM 361 RC 64484 HCPCS outpatient 922 691.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 829.8 999999999 719.16 875.9 case rate "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9514783_1 CDM 361 RC 64484 HCPCS outpatient 922 691.5 AETNA MCR ADV AETNA MCR ADV 719.16 78 999999999 719.16 875.9 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9514783_1 CDM 361 RC 64484 HCPCS outpatient 922 691.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 807.4 87.57 999999999 719.16 875.9 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9514783_1 CDM 361 RC 64484 HCPCS outpatient 922 691.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 784.35 85.07 999999999 719.16 875.9 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9514783_1 CDM 361 RC 64484 HCPCS outpatient 922 691.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 784.35 85.07 999999999 719.16 875.9 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9514783_1 CDM 361 RC 64484 HCPCS outpatient 922 691.5 MOLINA MCAID MOLINA MCAID 768.95 83.4 999999999 719.16 875.9 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9514783_1 CDM 361 RC 64484 HCPCS outpatient 922 691.5 MOLINA MCR ADV MOLINA MCR ADV 820.58 89 999999999 719.16 875.9 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9514783_1 CDM 361 RC 64484 HCPCS outpatient 922 691.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 820.58 89 999999999 719.16 875.9 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9514783_1 CDM 361 RC 64484 HCPCS outpatient 922 691.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 820.58 89 999999999 719.16 875.9 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9514783_1 CDM 361 RC 64484 HCPCS outpatient 922 691.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 829.8 90 999999999 719.16 875.9 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9514783_1 CDM 361 RC 64484 HCPCS outpatient 922 691.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 875.9 95 999999999 719.16 875.9 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9514783_1 CDM 361 RC 64484 HCPCS outpatient 922 691.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 875.9 95 999999999 719.16 875.9 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9514783_1 CDM 361 RC 64484 HCPCS outpatient 922 691.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 820.58 89 999999999 719.16 875.9 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9514783_1 CDM 361 RC 64484 HCPCS outpatient 922 691.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 811.36 88 999999999 719.16 875.9 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9514783_1 CDM 361 RC 64484 HCPCS outpatient 922 691.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 820.58 89 999999999 719.16 875.9 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9514783_50_1 CDM 361 RC 64484 HCPCS outpatient 1383 1037.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 1244.7 999999999 1078.74 1313.85 case rate "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9514783_50_1 CDM 361 RC 64484 HCPCS outpatient 1383 1037.25 AETNA MCR ADV AETNA MCR ADV 50 1078.74 78 999999999 1078.74 1313.85 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9514783_50_1 CDM 361 RC 64484 HCPCS outpatient 1383 1037.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 1211.09 87.57 999999999 1078.74 1313.85 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9514783_50_1 CDM 361 RC 64484 HCPCS outpatient 1383 1037.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 1176.52 85.07 999999999 1078.74 1313.85 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9514783_50_1 CDM 361 RC 64484 HCPCS outpatient 1383 1037.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 1176.52 85.07 999999999 1078.74 1313.85 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9514783_50_1 CDM 361 RC 64484 HCPCS outpatient 1383 1037.25 MOLINA MCAID MOLINA MCAID 50 1153.42 83.4 999999999 1078.74 1313.85 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9514783_50_1 CDM 361 RC 64484 HCPCS outpatient 1383 1037.25 MOLINA MCR ADV MOLINA MCR ADV 50 1230.87 89 999999999 1078.74 1313.85 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9514783_50_1 CDM 361 RC 64484 HCPCS outpatient 1383 1037.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 1230.87 89 999999999 1078.74 1313.85 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9514783_50_1 CDM 361 RC 64484 HCPCS outpatient 1383 1037.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 1230.87 89 999999999 1078.74 1313.85 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9514783_50_1 CDM 361 RC 64484 HCPCS outpatient 1383 1037.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 1244.7 90 999999999 1078.74 1313.85 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9514783_50_1 CDM 361 RC 64484 HCPCS outpatient 1383 1037.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 1313.85 95 999999999 1078.74 1313.85 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9514783_50_1 CDM 361 RC 64484 HCPCS outpatient 1383 1037.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 1313.85 95 999999999 1078.74 1313.85 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9514783_50_1 CDM 361 RC 64484 HCPCS outpatient 1383 1037.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 1230.87 89 999999999 1078.74 1313.85 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9514783_50_1 CDM 361 RC 64484 HCPCS outpatient 1383 1037.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 1217.04 88 999999999 1078.74 1313.85 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9514783_50_1 CDM 361 RC 64484 HCPCS outpatient 1383 1037.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 1230.87 89 999999999 1078.74 1313.85 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 9514839_2 CDM 410 RC 94640 HCPCS outpatient 375 281.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 337.5 90 999999999 292.5 356.25 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 9514839_2 CDM 410 RC 94640 HCPCS outpatient 375 281.25 AETNA MCR ADV AETNA MCR ADV 292.5 78 999999999 292.5 356.25 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 9514839_2 CDM 410 RC 94640 HCPCS outpatient 375 281.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 328.39 87.57 999999999 292.5 356.25 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 9514839_2 CDM 410 RC 94640 HCPCS outpatient 375 281.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 319.01 85.07 999999999 292.5 356.25 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 9514839_2 CDM 410 RC 94640 HCPCS outpatient 375 281.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 319.01 85.07 999999999 292.5 356.25 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 9514839_2 CDM 410 RC 94640 HCPCS outpatient 375 281.25 MOLINA MCAID MOLINA MCAID 312.75 83.4 999999999 292.5 356.25 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 9514839_2 CDM 410 RC 94640 HCPCS outpatient 375 281.25 MOLINA MCR ADV MOLINA MCR ADV 333.75 89 999999999 292.5 356.25 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 9514839_2 CDM 410 RC 94640 HCPCS outpatient 375 281.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 333.75 89 999999999 292.5 356.25 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 9514839_2 CDM 410 RC 94640 HCPCS outpatient 375 281.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 333.75 89 999999999 292.5 356.25 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 9514839_2 CDM 410 RC 94640 HCPCS outpatient 375 281.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 337.5 90 999999999 292.5 356.25 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 9514839_2 CDM 410 RC 94640 HCPCS outpatient 375 281.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 356.25 95 999999999 292.5 356.25 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 9514839_2 CDM 410 RC 94640 HCPCS outpatient 375 281.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 356.25 95 999999999 292.5 356.25 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 9514839_2 CDM 410 RC 94640 HCPCS outpatient 375 281.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 333.75 89 999999999 292.5 356.25 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 9514839_2 CDM 410 RC 94640 HCPCS outpatient 375 281.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 330 88 999999999 292.5 356.25 percent of total billed charges "PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURPOSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUM INDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE" 9514839_2 CDM 410 RC 94640 HCPCS outpatient 375 281.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 333.75 89 999999999 292.5 356.25 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 9514872_1 CDM 490 RC 64640 HCPCS outpatient 2419 1814.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 2177.1 999999999 1886.82 2298.05 case rate DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 9514872_1 CDM 490 RC 64640 HCPCS outpatient 2419 1814.25 AETNA MCR ADV AETNA MCR ADV 1886.82 78 999999999 1886.82 2298.05 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 9514872_1 CDM 490 RC 64640 HCPCS outpatient 2419 1814.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 2118.32 87.57 999999999 1886.82 2298.05 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 9514872_1 CDM 490 RC 64640 HCPCS outpatient 2419 1814.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 2057.84 85.07 999999999 1886.82 2298.05 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 9514872_1 CDM 490 RC 64640 HCPCS outpatient 2419 1814.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 2057.84 85.07 999999999 1886.82 2298.05 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 9514872_1 CDM 490 RC 64640 HCPCS outpatient 2419 1814.25 MOLINA MCAID MOLINA MCAID 2017.45 83.4 999999999 1886.82 2298.05 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 9514872_1 CDM 490 RC 64640 HCPCS outpatient 2419 1814.25 MOLINA MCR ADV MOLINA MCR ADV 2152.91 89 999999999 1886.82 2298.05 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 9514872_1 CDM 490 RC 64640 HCPCS outpatient 2419 1814.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 2152.91 89 999999999 1886.82 2298.05 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 9514872_1 CDM 490 RC 64640 HCPCS outpatient 2419 1814.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 2152.91 89 999999999 1886.82 2298.05 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 9514872_1 CDM 490 RC 64640 HCPCS outpatient 2419 1814.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 2177.1 90 999999999 1886.82 2298.05 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 9514872_1 CDM 490 RC 64640 HCPCS outpatient 2419 1814.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 2298.05 95 999999999 1886.82 2298.05 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 9514872_1 CDM 490 RC 64640 HCPCS outpatient 2419 1814.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 2298.05 95 999999999 1886.82 2298.05 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 9514872_1 CDM 490 RC 64640 HCPCS outpatient 2419 1814.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 2152.91 89 999999999 1886.82 2298.05 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 9514872_1 CDM 490 RC 64640 HCPCS outpatient 2419 1814.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 2128.72 88 999999999 1886.82 2298.05 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 9514872_1 CDM 490 RC 64640 HCPCS outpatient 2419 1814.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 2152.91 89 999999999 1886.82 2298.05 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 9514872_50_1 CDM 490 RC 64640 HCPCS outpatient 3626 2719.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 3263.4 999999999 2828.28 3444.7 case rate DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 9514872_50_1 CDM 490 RC 64640 HCPCS outpatient 3626 2719.5 AETNA MCR ADV AETNA MCR ADV 50 2828.28 78 999999999 2828.28 3444.7 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 9514872_50_1 CDM 490 RC 64640 HCPCS outpatient 3626 2719.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 3175.29 87.57 999999999 2828.28 3444.7 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 9514872_50_1 CDM 490 RC 64640 HCPCS outpatient 3626 2719.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 3084.64 85.07 999999999 2828.28 3444.7 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 9514872_50_1 CDM 490 RC 64640 HCPCS outpatient 3626 2719.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 3084.64 85.07 999999999 2828.28 3444.7 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 9514872_50_1 CDM 490 RC 64640 HCPCS outpatient 3626 2719.5 MOLINA MCAID MOLINA MCAID 50 3024.08 83.4 999999999 2828.28 3444.7 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 9514872_50_1 CDM 490 RC 64640 HCPCS outpatient 3626 2719.5 MOLINA MCR ADV MOLINA MCR ADV 50 3227.14 89 999999999 2828.28 3444.7 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 9514872_50_1 CDM 490 RC 64640 HCPCS outpatient 3626 2719.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 3227.14 89 999999999 2828.28 3444.7 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 9514872_50_1 CDM 490 RC 64640 HCPCS outpatient 3626 2719.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 3227.14 89 999999999 2828.28 3444.7 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 9514872_50_1 CDM 490 RC 64640 HCPCS outpatient 3626 2719.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 3263.4 90 999999999 2828.28 3444.7 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 9514872_50_1 CDM 490 RC 64640 HCPCS outpatient 3626 2719.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 3444.7 95 999999999 2828.28 3444.7 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 9514872_50_1 CDM 490 RC 64640 HCPCS outpatient 3626 2719.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 3444.7 95 999999999 2828.28 3444.7 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 9514872_50_1 CDM 490 RC 64640 HCPCS outpatient 3626 2719.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 3227.14 89 999999999 2828.28 3444.7 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 9514872_50_1 CDM 490 RC 64640 HCPCS outpatient 3626 2719.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 3190.88 88 999999999 2828.28 3444.7 percent of total billed charges DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 9514872_50_1 CDM 490 RC 64640 HCPCS outpatient 3626 2719.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 3227.14 89 999999999 2828.28 3444.7 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL" 9514900_1 CDM 352 RC 74176 HCPCS outpatient 2052 1539 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1846.8 90 999999999 1600.56 1949.4 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL" 9514900_1 CDM 352 RC 74176 HCPCS outpatient 2052 1539 AETNA MCR ADV AETNA MCR ADV 1600.56 78 999999999 1600.56 1949.4 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL" 9514900_1 CDM 352 RC 74176 HCPCS outpatient 2052 1539 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1796.94 87.57 999999999 1600.56 1949.4 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL" 9514900_1 CDM 352 RC 74176 HCPCS outpatient 2052 1539 COORDINATED CARE MCAID COORDINATED CARE MCAID 1745.64 85.07 999999999 1600.56 1949.4 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL" 9514900_1 CDM 352 RC 74176 HCPCS outpatient 2052 1539 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1745.64 85.07 999999999 1600.56 1949.4 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL" 9514900_1 CDM 352 RC 74176 HCPCS outpatient 2052 1539 MOLINA MCAID MOLINA MCAID 1711.37 83.4 999999999 1600.56 1949.4 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL" 9514900_1 CDM 352 RC 74176 HCPCS outpatient 2052 1539 MOLINA MCR ADV MOLINA MCR ADV 1826.28 89 999999999 1600.56 1949.4 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL" 9514900_1 CDM 352 RC 74176 HCPCS outpatient 2052 1539 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1826.28 89 999999999 1600.56 1949.4 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL" 9514900_1 CDM 352 RC 74176 HCPCS outpatient 2052 1539 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1826.28 89 999999999 1600.56 1949.4 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL" 9514900_1 CDM 352 RC 74176 HCPCS outpatient 2052 1539 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1846.8 90 999999999 1600.56 1949.4 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL" 9514900_1 CDM 352 RC 74176 HCPCS outpatient 2052 1539 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1949.4 95 999999999 1600.56 1949.4 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL" 9514900_1 CDM 352 RC 74176 HCPCS outpatient 2052 1539 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1949.4 95 999999999 1600.56 1949.4 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL" 9514900_1 CDM 352 RC 74176 HCPCS outpatient 2052 1539 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1826.28 89 999999999 1600.56 1949.4 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL" 9514900_1 CDM 352 RC 74176 HCPCS outpatient 2052 1539 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1805.76 88 999999999 1600.56 1949.4 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL" 9514900_1 CDM 352 RC 74176 HCPCS outpatient 2052 1539 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1826.28 89 999999999 1600.56 1949.4 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITH CONTRAST MATERIAL(S)" 9514901_1 CDM 352 RC 74177 HCPCS outpatient 2734 2050.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 2460.6 90 999999999 2132.52 2597.3 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITH CONTRAST MATERIAL(S)" 9514901_1 CDM 352 RC 74177 HCPCS outpatient 2734 2050.5 AETNA MCR ADV AETNA MCR ADV 2132.52 78 999999999 2132.52 2597.3 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITH CONTRAST MATERIAL(S)" 9514901_1 CDM 352 RC 74177 HCPCS outpatient 2734 2050.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 2394.16 87.57 999999999 2132.52 2597.3 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITH CONTRAST MATERIAL(S)" 9514901_1 CDM 352 RC 74177 HCPCS outpatient 2734 2050.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 2325.81 85.07 999999999 2132.52 2597.3 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITH CONTRAST MATERIAL(S)" 9514901_1 CDM 352 RC 74177 HCPCS outpatient 2734 2050.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 2325.81 85.07 999999999 2132.52 2597.3 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITH CONTRAST MATERIAL(S)" 9514901_1 CDM 352 RC 74177 HCPCS outpatient 2734 2050.5 MOLINA MCAID MOLINA MCAID 2280.16 83.4 999999999 2132.52 2597.3 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITH CONTRAST MATERIAL(S)" 9514901_1 CDM 352 RC 74177 HCPCS outpatient 2734 2050.5 MOLINA MCR ADV MOLINA MCR ADV 2433.26 89 999999999 2132.52 2597.3 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITH CONTRAST MATERIAL(S)" 9514901_1 CDM 352 RC 74177 HCPCS outpatient 2734 2050.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 2433.26 89 999999999 2132.52 2597.3 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITH CONTRAST MATERIAL(S)" 9514901_1 CDM 352 RC 74177 HCPCS outpatient 2734 2050.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 2433.26 89 999999999 2132.52 2597.3 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITH CONTRAST MATERIAL(S)" 9514901_1 CDM 352 RC 74177 HCPCS outpatient 2734 2050.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 2460.6 90 999999999 2132.52 2597.3 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITH CONTRAST MATERIAL(S)" 9514901_1 CDM 352 RC 74177 HCPCS outpatient 2734 2050.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 2597.3 95 999999999 2132.52 2597.3 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITH CONTRAST MATERIAL(S)" 9514901_1 CDM 352 RC 74177 HCPCS outpatient 2734 2050.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 2597.3 95 999999999 2132.52 2597.3 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITH CONTRAST MATERIAL(S)" 9514901_1 CDM 352 RC 74177 HCPCS outpatient 2734 2050.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 2433.26 89 999999999 2132.52 2597.3 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITH CONTRAST MATERIAL(S)" 9514901_1 CDM 352 RC 74177 HCPCS outpatient 2734 2050.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 2405.92 88 999999999 2132.52 2597.3 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITH CONTRAST MATERIAL(S)" 9514901_1 CDM 352 RC 74177 HCPCS outpatient 2734 2050.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 2433.26 89 999999999 2132.52 2597.3 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL IN ONE OR BOTH BODY REGIONS, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS IN ONE OR BOTH BODY REGIONS" 9514902_1 CDM 350 RC 74178 HCPCS outpatient 3305 2478.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 2974.5 90 999999999 2577.9 3139.75 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL IN ONE OR BOTH BODY REGIONS, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS IN ONE OR BOTH BODY REGIONS" 9514902_1 CDM 350 RC 74178 HCPCS outpatient 3305 2478.75 AETNA MCR ADV AETNA MCR ADV 2577.9 78 999999999 2577.9 3139.75 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL IN ONE OR BOTH BODY REGIONS, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS IN ONE OR BOTH BODY REGIONS" 9514902_1 CDM 350 RC 74178 HCPCS outpatient 3305 2478.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 2894.19 87.57 999999999 2577.9 3139.75 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL IN ONE OR BOTH BODY REGIONS, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS IN ONE OR BOTH BODY REGIONS" 9514902_1 CDM 350 RC 74178 HCPCS outpatient 3305 2478.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 2811.56 85.07 999999999 2577.9 3139.75 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL IN ONE OR BOTH BODY REGIONS, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS IN ONE OR BOTH BODY REGIONS" 9514902_1 CDM 350 RC 74178 HCPCS outpatient 3305 2478.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 2811.56 85.07 999999999 2577.9 3139.75 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL IN ONE OR BOTH BODY REGIONS, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS IN ONE OR BOTH BODY REGIONS" 9514902_1 CDM 350 RC 74178 HCPCS outpatient 3305 2478.75 MOLINA MCAID MOLINA MCAID 2756.37 83.4 999999999 2577.9 3139.75 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL IN ONE OR BOTH BODY REGIONS, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS IN ONE OR BOTH BODY REGIONS" 9514902_1 CDM 350 RC 74178 HCPCS outpatient 3305 2478.75 MOLINA MCR ADV MOLINA MCR ADV 2941.45 89 999999999 2577.9 3139.75 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL IN ONE OR BOTH BODY REGIONS, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS IN ONE OR BOTH BODY REGIONS" 9514902_1 CDM 350 RC 74178 HCPCS outpatient 3305 2478.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 2941.45 89 999999999 2577.9 3139.75 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL IN ONE OR BOTH BODY REGIONS, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS IN ONE OR BOTH BODY REGIONS" 9514902_1 CDM 350 RC 74178 HCPCS outpatient 3305 2478.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 2941.45 89 999999999 2577.9 3139.75 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL IN ONE OR BOTH BODY REGIONS, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS IN ONE OR BOTH BODY REGIONS" 9514902_1 CDM 350 RC 74178 HCPCS outpatient 3305 2478.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 2974.5 90 999999999 2577.9 3139.75 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL IN ONE OR BOTH BODY REGIONS, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS IN ONE OR BOTH BODY REGIONS" 9514902_1 CDM 350 RC 74178 HCPCS outpatient 3305 2478.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 3139.75 95 999999999 2577.9 3139.75 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL IN ONE OR BOTH BODY REGIONS, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS IN ONE OR BOTH BODY REGIONS" 9514902_1 CDM 350 RC 74178 HCPCS outpatient 3305 2478.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 3139.75 95 999999999 2577.9 3139.75 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL IN ONE OR BOTH BODY REGIONS, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS IN ONE OR BOTH BODY REGIONS" 9514902_1 CDM 350 RC 74178 HCPCS outpatient 3305 2478.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 2941.45 89 999999999 2577.9 3139.75 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL IN ONE OR BOTH BODY REGIONS, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS IN ONE OR BOTH BODY REGIONS" 9514902_1 CDM 350 RC 74178 HCPCS outpatient 3305 2478.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 2908.4 88 999999999 2577.9 3139.75 percent of total billed charges "COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL IN ONE OR BOTH BODY REGIONS, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS IN ONE OR BOTH BODY REGIONS" 9514902_1 CDM 350 RC 74178 HCPCS outpatient 3305 2478.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 2941.45 89 999999999 2577.9 3139.75 percent of total billed charges "GASTRIC INTUBATION AND ASPIRATION(S) THERAPEUTIC, NECESSITATING PHYSICIAN'S SKILL (EG, FOR GASTROINTESTINAL HEMORRHAGE), INCLUDING LAVAGE IF PERFORMED" 9514910_1 CDM 750 RC 43753 HCPCS outpatient 236 177 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 212.4 999999999 184.08 224.2 case rate "GASTRIC INTUBATION AND ASPIRATION(S) THERAPEUTIC, NECESSITATING PHYSICIAN'S SKILL (EG, FOR GASTROINTESTINAL HEMORRHAGE), INCLUDING LAVAGE IF PERFORMED" 9514910_1 CDM 750 RC 43753 HCPCS outpatient 236 177 AETNA MCR ADV AETNA MCR ADV 184.08 78 999999999 184.08 224.2 percent of total billed charges "GASTRIC INTUBATION AND ASPIRATION(S) THERAPEUTIC, NECESSITATING PHYSICIAN'S SKILL (EG, FOR GASTROINTESTINAL HEMORRHAGE), INCLUDING LAVAGE IF PERFORMED" 9514910_1 CDM 750 RC 43753 HCPCS outpatient 236 177 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 206.67 87.57 999999999 184.08 224.2 percent of total billed charges "GASTRIC INTUBATION AND ASPIRATION(S) THERAPEUTIC, NECESSITATING PHYSICIAN'S SKILL (EG, FOR GASTROINTESTINAL HEMORRHAGE), INCLUDING LAVAGE IF PERFORMED" 9514910_1 CDM 750 RC 43753 HCPCS outpatient 236 177 COORDINATED CARE MCAID COORDINATED CARE MCAID 200.77 85.07 999999999 184.08 224.2 percent of total billed charges "GASTRIC INTUBATION AND ASPIRATION(S) THERAPEUTIC, NECESSITATING PHYSICIAN'S SKILL (EG, FOR GASTROINTESTINAL HEMORRHAGE), INCLUDING LAVAGE IF PERFORMED" 9514910_1 CDM 750 RC 43753 HCPCS outpatient 236 177 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 200.77 85.07 999999999 184.08 224.2 percent of total billed charges "GASTRIC INTUBATION AND ASPIRATION(S) THERAPEUTIC, NECESSITATING PHYSICIAN'S SKILL (EG, FOR GASTROINTESTINAL HEMORRHAGE), INCLUDING LAVAGE IF PERFORMED" 9514910_1 CDM 750 RC 43753 HCPCS outpatient 236 177 MOLINA MCAID MOLINA MCAID 196.82 83.4 999999999 184.08 224.2 percent of total billed charges "GASTRIC INTUBATION AND ASPIRATION(S) THERAPEUTIC, NECESSITATING PHYSICIAN'S SKILL (EG, FOR GASTROINTESTINAL HEMORRHAGE), INCLUDING LAVAGE IF PERFORMED" 9514910_1 CDM 750 RC 43753 HCPCS outpatient 236 177 MOLINA MCR ADV MOLINA MCR ADV 210.04 89 999999999 184.08 224.2 percent of total billed charges "GASTRIC INTUBATION AND ASPIRATION(S) THERAPEUTIC, NECESSITATING PHYSICIAN'S SKILL (EG, FOR GASTROINTESTINAL HEMORRHAGE), INCLUDING LAVAGE IF PERFORMED" 9514910_1 CDM 750 RC 43753 HCPCS outpatient 236 177 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 210.04 89 999999999 184.08 224.2 percent of total billed charges "GASTRIC INTUBATION AND ASPIRATION(S) THERAPEUTIC, NECESSITATING PHYSICIAN'S SKILL (EG, FOR GASTROINTESTINAL HEMORRHAGE), INCLUDING LAVAGE IF PERFORMED" 9514910_1 CDM 750 RC 43753 HCPCS outpatient 236 177 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 210.04 89 999999999 184.08 224.2 percent of total billed charges "GASTRIC INTUBATION AND ASPIRATION(S) THERAPEUTIC, NECESSITATING PHYSICIAN'S SKILL (EG, FOR GASTROINTESTINAL HEMORRHAGE), INCLUDING LAVAGE IF PERFORMED" 9514910_1 CDM 750 RC 43753 HCPCS outpatient 236 177 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 212.4 90 999999999 184.08 224.2 percent of total billed charges "GASTRIC INTUBATION AND ASPIRATION(S) THERAPEUTIC, NECESSITATING PHYSICIAN'S SKILL (EG, FOR GASTROINTESTINAL HEMORRHAGE), INCLUDING LAVAGE IF PERFORMED" 9514910_1 CDM 750 RC 43753 HCPCS outpatient 236 177 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 224.2 95 999999999 184.08 224.2 percent of total billed charges "GASTRIC INTUBATION AND ASPIRATION(S) THERAPEUTIC, NECESSITATING PHYSICIAN'S SKILL (EG, FOR GASTROINTESTINAL HEMORRHAGE), INCLUDING LAVAGE IF PERFORMED" 9514910_1 CDM 750 RC 43753 HCPCS outpatient 236 177 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 224.2 95 999999999 184.08 224.2 percent of total billed charges "GASTRIC INTUBATION AND ASPIRATION(S) THERAPEUTIC, NECESSITATING PHYSICIAN'S SKILL (EG, FOR GASTROINTESTINAL HEMORRHAGE), INCLUDING LAVAGE IF PERFORMED" 9514910_1 CDM 750 RC 43753 HCPCS outpatient 236 177 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 210.04 89 999999999 184.08 224.2 percent of total billed charges "GASTRIC INTUBATION AND ASPIRATION(S) THERAPEUTIC, NECESSITATING PHYSICIAN'S SKILL (EG, FOR GASTROINTESTINAL HEMORRHAGE), INCLUDING LAVAGE IF PERFORMED" 9514910_1 CDM 750 RC 43753 HCPCS outpatient 236 177 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 207.68 88 999999999 184.08 224.2 percent of total billed charges "GASTRIC INTUBATION AND ASPIRATION(S) THERAPEUTIC, NECESSITATING PHYSICIAN'S SKILL (EG, FOR GASTROINTESTINAL HEMORRHAGE), INCLUDING LAVAGE IF PERFORMED" 9514910_1 CDM 750 RC 43753 HCPCS outpatient 236 177 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 210.04 89 999999999 184.08 224.2 percent of total billed charges "GASTRIC INTUBATION AND ASPIRATION(S) THERAPEUTIC, NECESSITATING PHYSICIAN'S SKILL (EG, FOR GASTROINTESTINAL HEMORRHAGE), INCLUDING LAVAGE IF PERFORMED" 9514910_2 CDM 750 RC 43753 HCPCS outpatient 354 265.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 318.6 999999999 276.12 336.3 case rate "GASTRIC INTUBATION AND ASPIRATION(S) THERAPEUTIC, NECESSITATING PHYSICIAN'S SKILL (EG, FOR GASTROINTESTINAL HEMORRHAGE), INCLUDING LAVAGE IF PERFORMED" 9514910_2 CDM 750 RC 43753 HCPCS outpatient 354 265.5 AETNA MCR ADV AETNA MCR ADV 276.12 78 999999999 276.12 336.3 percent of total billed charges "GASTRIC INTUBATION AND ASPIRATION(S) THERAPEUTIC, NECESSITATING PHYSICIAN'S SKILL (EG, FOR GASTROINTESTINAL HEMORRHAGE), INCLUDING LAVAGE IF PERFORMED" 9514910_2 CDM 750 RC 43753 HCPCS outpatient 354 265.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 310 87.57 999999999 276.12 336.3 percent of total billed charges "GASTRIC INTUBATION AND ASPIRATION(S) THERAPEUTIC, NECESSITATING PHYSICIAN'S SKILL (EG, FOR GASTROINTESTINAL HEMORRHAGE), INCLUDING LAVAGE IF PERFORMED" 9514910_2 CDM 750 RC 43753 HCPCS outpatient 354 265.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 301.15 85.07 999999999 276.12 336.3 percent of total billed charges "GASTRIC INTUBATION AND ASPIRATION(S) THERAPEUTIC, NECESSITATING PHYSICIAN'S SKILL (EG, FOR GASTROINTESTINAL HEMORRHAGE), INCLUDING LAVAGE IF PERFORMED" 9514910_2 CDM 750 RC 43753 HCPCS outpatient 354 265.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 301.15 85.07 999999999 276.12 336.3 percent of total billed charges "GASTRIC INTUBATION AND ASPIRATION(S) THERAPEUTIC, NECESSITATING PHYSICIAN'S SKILL (EG, FOR GASTROINTESTINAL HEMORRHAGE), INCLUDING LAVAGE IF PERFORMED" 9514910_2 CDM 750 RC 43753 HCPCS outpatient 354 265.5 MOLINA MCAID MOLINA MCAID 295.24 83.4 999999999 276.12 336.3 percent of total billed charges "GASTRIC INTUBATION AND ASPIRATION(S) THERAPEUTIC, NECESSITATING PHYSICIAN'S SKILL (EG, FOR GASTROINTESTINAL HEMORRHAGE), INCLUDING LAVAGE IF PERFORMED" 9514910_2 CDM 750 RC 43753 HCPCS outpatient 354 265.5 MOLINA MCR ADV MOLINA MCR ADV 315.06 89 999999999 276.12 336.3 percent of total billed charges "GASTRIC INTUBATION AND ASPIRATION(S) THERAPEUTIC, NECESSITATING PHYSICIAN'S SKILL (EG, FOR GASTROINTESTINAL HEMORRHAGE), INCLUDING LAVAGE IF PERFORMED" 9514910_2 CDM 750 RC 43753 HCPCS outpatient 354 265.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 315.06 89 999999999 276.12 336.3 percent of total billed charges "GASTRIC INTUBATION AND ASPIRATION(S) THERAPEUTIC, NECESSITATING PHYSICIAN'S SKILL (EG, FOR GASTROINTESTINAL HEMORRHAGE), INCLUDING LAVAGE IF PERFORMED" 9514910_2 CDM 750 RC 43753 HCPCS outpatient 354 265.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 315.06 89 999999999 276.12 336.3 percent of total billed charges "GASTRIC INTUBATION AND ASPIRATION(S) THERAPEUTIC, NECESSITATING PHYSICIAN'S SKILL (EG, FOR GASTROINTESTINAL HEMORRHAGE), INCLUDING LAVAGE IF PERFORMED" 9514910_2 CDM 750 RC 43753 HCPCS outpatient 354 265.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 318.6 90 999999999 276.12 336.3 percent of total billed charges "GASTRIC INTUBATION AND ASPIRATION(S) THERAPEUTIC, NECESSITATING PHYSICIAN'S SKILL (EG, FOR GASTROINTESTINAL HEMORRHAGE), INCLUDING LAVAGE IF PERFORMED" 9514910_2 CDM 750 RC 43753 HCPCS outpatient 354 265.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 336.3 95 999999999 276.12 336.3 percent of total billed charges "GASTRIC INTUBATION AND ASPIRATION(S) THERAPEUTIC, NECESSITATING PHYSICIAN'S SKILL (EG, FOR GASTROINTESTINAL HEMORRHAGE), INCLUDING LAVAGE IF PERFORMED" 9514910_2 CDM 750 RC 43753 HCPCS outpatient 354 265.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 336.3 95 999999999 276.12 336.3 percent of total billed charges "GASTRIC INTUBATION AND ASPIRATION(S) THERAPEUTIC, NECESSITATING PHYSICIAN'S SKILL (EG, FOR GASTROINTESTINAL HEMORRHAGE), INCLUDING LAVAGE IF PERFORMED" 9514910_2 CDM 750 RC 43753 HCPCS outpatient 354 265.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 315.06 89 999999999 276.12 336.3 percent of total billed charges "GASTRIC INTUBATION AND ASPIRATION(S) THERAPEUTIC, NECESSITATING PHYSICIAN'S SKILL (EG, FOR GASTROINTESTINAL HEMORRHAGE), INCLUDING LAVAGE IF PERFORMED" 9514910_2 CDM 750 RC 43753 HCPCS outpatient 354 265.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 311.52 88 999999999 276.12 336.3 percent of total billed charges "GASTRIC INTUBATION AND ASPIRATION(S) THERAPEUTIC, NECESSITATING PHYSICIAN'S SKILL (EG, FOR GASTROINTESTINAL HEMORRHAGE), INCLUDING LAVAGE IF PERFORMED" 9514910_2 CDM 750 RC 43753 HCPCS outpatient 354 265.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 315.06 89 999999999 276.12 336.3 percent of total billed charges "ULTRASOUND, COMPLETE JOINT (IE, JOINT SPACE AND PERI-ARTICULAR SOFT-TISSUE STRUCTURES), REAL-TIME WITH IMAGE DOCUMENTATION" 9514947_1 CDM 402 RC 76881 HCPCS outpatient 736 552 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 662.4 90 999999999 574.08 699.2 percent of total billed charges "ULTRASOUND, COMPLETE JOINT (IE, JOINT SPACE AND PERI-ARTICULAR SOFT-TISSUE STRUCTURES), REAL-TIME WITH IMAGE DOCUMENTATION" 9514947_1 CDM 402 RC 76881 HCPCS outpatient 736 552 AETNA MCR ADV AETNA MCR ADV 574.08 78 999999999 574.08 699.2 percent of total billed charges "ULTRASOUND, COMPLETE JOINT (IE, JOINT SPACE AND PERI-ARTICULAR SOFT-TISSUE STRUCTURES), REAL-TIME WITH IMAGE DOCUMENTATION" 9514947_1 CDM 402 RC 76881 HCPCS outpatient 736 552 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 644.52 87.57 999999999 574.08 699.2 percent of total billed charges "ULTRASOUND, COMPLETE JOINT (IE, JOINT SPACE AND PERI-ARTICULAR SOFT-TISSUE STRUCTURES), REAL-TIME WITH IMAGE DOCUMENTATION" 9514947_1 CDM 402 RC 76881 HCPCS outpatient 736 552 COORDINATED CARE MCAID COORDINATED CARE MCAID 626.12 85.07 999999999 574.08 699.2 percent of total billed charges "ULTRASOUND, COMPLETE JOINT (IE, JOINT SPACE AND PERI-ARTICULAR SOFT-TISSUE STRUCTURES), REAL-TIME WITH IMAGE DOCUMENTATION" 9514947_1 CDM 402 RC 76881 HCPCS outpatient 736 552 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 626.12 85.07 999999999 574.08 699.2 percent of total billed charges "ULTRASOUND, COMPLETE JOINT (IE, JOINT SPACE AND PERI-ARTICULAR SOFT-TISSUE STRUCTURES), REAL-TIME WITH IMAGE DOCUMENTATION" 9514947_1 CDM 402 RC 76881 HCPCS outpatient 736 552 MOLINA MCAID MOLINA MCAID 613.82 83.4 999999999 574.08 699.2 percent of total billed charges "ULTRASOUND, COMPLETE JOINT (IE, JOINT SPACE AND PERI-ARTICULAR SOFT-TISSUE STRUCTURES), REAL-TIME WITH IMAGE DOCUMENTATION" 9514947_1 CDM 402 RC 76881 HCPCS outpatient 736 552 MOLINA MCR ADV MOLINA MCR ADV 655.04 89 999999999 574.08 699.2 percent of total billed charges "ULTRASOUND, COMPLETE JOINT (IE, JOINT SPACE AND PERI-ARTICULAR SOFT-TISSUE STRUCTURES), REAL-TIME WITH IMAGE DOCUMENTATION" 9514947_1 CDM 402 RC 76881 HCPCS outpatient 736 552 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 655.04 89 999999999 574.08 699.2 percent of total billed charges "ULTRASOUND, COMPLETE JOINT (IE, JOINT SPACE AND PERI-ARTICULAR SOFT-TISSUE STRUCTURES), REAL-TIME WITH IMAGE DOCUMENTATION" 9514947_1 CDM 402 RC 76881 HCPCS outpatient 736 552 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 655.04 89 999999999 574.08 699.2 percent of total billed charges "ULTRASOUND, COMPLETE JOINT (IE, JOINT SPACE AND PERI-ARTICULAR SOFT-TISSUE STRUCTURES), REAL-TIME WITH IMAGE DOCUMENTATION" 9514947_1 CDM 402 RC 76881 HCPCS outpatient 736 552 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 662.4 90 999999999 574.08 699.2 percent of total billed charges "ULTRASOUND, COMPLETE JOINT (IE, JOINT SPACE AND PERI-ARTICULAR SOFT-TISSUE STRUCTURES), REAL-TIME WITH IMAGE DOCUMENTATION" 9514947_1 CDM 402 RC 76881 HCPCS outpatient 736 552 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 699.2 95 999999999 574.08 699.2 percent of total billed charges "ULTRASOUND, COMPLETE JOINT (IE, JOINT SPACE AND PERI-ARTICULAR SOFT-TISSUE STRUCTURES), REAL-TIME WITH IMAGE DOCUMENTATION" 9514947_1 CDM 402 RC 76881 HCPCS outpatient 736 552 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 699.2 95 999999999 574.08 699.2 percent of total billed charges "ULTRASOUND, COMPLETE JOINT (IE, JOINT SPACE AND PERI-ARTICULAR SOFT-TISSUE STRUCTURES), REAL-TIME WITH IMAGE DOCUMENTATION" 9514947_1 CDM 402 RC 76881 HCPCS outpatient 736 552 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 655.04 89 999999999 574.08 699.2 percent of total billed charges "ULTRASOUND, COMPLETE JOINT (IE, JOINT SPACE AND PERI-ARTICULAR SOFT-TISSUE STRUCTURES), REAL-TIME WITH IMAGE DOCUMENTATION" 9514947_1 CDM 402 RC 76881 HCPCS outpatient 736 552 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 647.68 88 999999999 574.08 699.2 percent of total billed charges "ULTRASOUND, COMPLETE JOINT (IE, JOINT SPACE AND PERI-ARTICULAR SOFT-TISSUE STRUCTURES), REAL-TIME WITH IMAGE DOCUMENTATION" 9514947_1 CDM 402 RC 76881 HCPCS outpatient 736 552 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 655.04 89 999999999 574.08 699.2 percent of total billed charges "ULTRASOUND, LIMITED, JOINT OR FOCAL EVALUATION OF OTHER NONVASCULAR EXTREMITY STRUCTURE(S) (EG, JOINT SPACE, PERI-ARTICULAR TENDON[S], MUSCLE[S], NERVE[S], OTHER SOFT-TISSUE STRUCTURE[S], OR SOFT-TISSUE MASS[ES]), REAL-TIME WITH IMAGE DOCUMENTATION" 9514948_1 CDM 402 RC 76882 HCPCS outpatient 427 320.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 384.3 90 999999999 333.06 405.65 percent of total billed charges "ULTRASOUND, LIMITED, JOINT OR FOCAL EVALUATION OF OTHER NONVASCULAR EXTREMITY STRUCTURE(S) (EG, JOINT SPACE, PERI-ARTICULAR TENDON[S], MUSCLE[S], NERVE[S], OTHER SOFT-TISSUE STRUCTURE[S], OR SOFT-TISSUE MASS[ES]), REAL-TIME WITH IMAGE DOCUMENTATION" 9514948_1 CDM 402 RC 76882 HCPCS outpatient 427 320.25 AETNA MCR ADV AETNA MCR ADV 333.06 78 999999999 333.06 405.65 percent of total billed charges "ULTRASOUND, LIMITED, JOINT OR FOCAL EVALUATION OF OTHER NONVASCULAR EXTREMITY STRUCTURE(S) (EG, JOINT SPACE, PERI-ARTICULAR TENDON[S], MUSCLE[S], NERVE[S], OTHER SOFT-TISSUE STRUCTURE[S], OR SOFT-TISSUE MASS[ES]), REAL-TIME WITH IMAGE DOCUMENTATION" 9514948_1 CDM 402 RC 76882 HCPCS outpatient 427 320.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 373.92 87.57 999999999 333.06 405.65 percent of total billed charges "ULTRASOUND, LIMITED, JOINT OR FOCAL EVALUATION OF OTHER NONVASCULAR EXTREMITY STRUCTURE(S) (EG, JOINT SPACE, PERI-ARTICULAR TENDON[S], MUSCLE[S], NERVE[S], OTHER SOFT-TISSUE STRUCTURE[S], OR SOFT-TISSUE MASS[ES]), REAL-TIME WITH IMAGE DOCUMENTATION" 9514948_1 CDM 402 RC 76882 HCPCS outpatient 427 320.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 363.25 85.07 999999999 333.06 405.65 percent of total billed charges "ULTRASOUND, LIMITED, JOINT OR FOCAL EVALUATION OF OTHER NONVASCULAR EXTREMITY STRUCTURE(S) (EG, JOINT SPACE, PERI-ARTICULAR TENDON[S], MUSCLE[S], NERVE[S], OTHER SOFT-TISSUE STRUCTURE[S], OR SOFT-TISSUE MASS[ES]), REAL-TIME WITH IMAGE DOCUMENTATION" 9514948_1 CDM 402 RC 76882 HCPCS outpatient 427 320.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 363.25 85.07 999999999 333.06 405.65 percent of total billed charges "ULTRASOUND, LIMITED, JOINT OR FOCAL EVALUATION OF OTHER NONVASCULAR EXTREMITY STRUCTURE(S) (EG, JOINT SPACE, PERI-ARTICULAR TENDON[S], MUSCLE[S], NERVE[S], OTHER SOFT-TISSUE STRUCTURE[S], OR SOFT-TISSUE MASS[ES]), REAL-TIME WITH IMAGE DOCUMENTATION" 9514948_1 CDM 402 RC 76882 HCPCS outpatient 427 320.25 MOLINA MCAID MOLINA MCAID 356.12 83.4 999999999 333.06 405.65 percent of total billed charges "ULTRASOUND, LIMITED, JOINT OR FOCAL EVALUATION OF OTHER NONVASCULAR EXTREMITY STRUCTURE(S) (EG, JOINT SPACE, PERI-ARTICULAR TENDON[S], MUSCLE[S], NERVE[S], OTHER SOFT-TISSUE STRUCTURE[S], OR SOFT-TISSUE MASS[ES]), REAL-TIME WITH IMAGE DOCUMENTATION" 9514948_1 CDM 402 RC 76882 HCPCS outpatient 427 320.25 MOLINA MCR ADV MOLINA MCR ADV 380.03 89 999999999 333.06 405.65 percent of total billed charges "ULTRASOUND, LIMITED, JOINT OR FOCAL EVALUATION OF OTHER NONVASCULAR EXTREMITY STRUCTURE(S) (EG, JOINT SPACE, PERI-ARTICULAR TENDON[S], MUSCLE[S], NERVE[S], OTHER SOFT-TISSUE STRUCTURE[S], OR SOFT-TISSUE MASS[ES]), REAL-TIME WITH IMAGE DOCUMENTATION" 9514948_1 CDM 402 RC 76882 HCPCS outpatient 427 320.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 380.03 89 999999999 333.06 405.65 percent of total billed charges "ULTRASOUND, LIMITED, JOINT OR FOCAL EVALUATION OF OTHER NONVASCULAR EXTREMITY STRUCTURE(S) (EG, JOINT SPACE, PERI-ARTICULAR TENDON[S], MUSCLE[S], NERVE[S], OTHER SOFT-TISSUE STRUCTURE[S], OR SOFT-TISSUE MASS[ES]), REAL-TIME WITH IMAGE DOCUMENTATION" 9514948_1 CDM 402 RC 76882 HCPCS outpatient 427 320.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 380.03 89 999999999 333.06 405.65 percent of total billed charges "ULTRASOUND, LIMITED, JOINT OR FOCAL EVALUATION OF OTHER NONVASCULAR EXTREMITY STRUCTURE(S) (EG, JOINT SPACE, PERI-ARTICULAR TENDON[S], MUSCLE[S], NERVE[S], OTHER SOFT-TISSUE STRUCTURE[S], OR SOFT-TISSUE MASS[ES]), REAL-TIME WITH IMAGE DOCUMENTATION" 9514948_1 CDM 402 RC 76882 HCPCS outpatient 427 320.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 384.3 90 999999999 333.06 405.65 percent of total billed charges "ULTRASOUND, LIMITED, JOINT OR FOCAL EVALUATION OF OTHER NONVASCULAR EXTREMITY STRUCTURE(S) (EG, JOINT SPACE, PERI-ARTICULAR TENDON[S], MUSCLE[S], NERVE[S], OTHER SOFT-TISSUE STRUCTURE[S], OR SOFT-TISSUE MASS[ES]), REAL-TIME WITH IMAGE DOCUMENTATION" 9514948_1 CDM 402 RC 76882 HCPCS outpatient 427 320.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 405.65 95 999999999 333.06 405.65 percent of total billed charges "ULTRASOUND, LIMITED, JOINT OR FOCAL EVALUATION OF OTHER NONVASCULAR EXTREMITY STRUCTURE(S) (EG, JOINT SPACE, PERI-ARTICULAR TENDON[S], MUSCLE[S], NERVE[S], OTHER SOFT-TISSUE STRUCTURE[S], OR SOFT-TISSUE MASS[ES]), REAL-TIME WITH IMAGE DOCUMENTATION" 9514948_1 CDM 402 RC 76882 HCPCS outpatient 427 320.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 405.65 95 999999999 333.06 405.65 percent of total billed charges "ULTRASOUND, LIMITED, JOINT OR FOCAL EVALUATION OF OTHER NONVASCULAR EXTREMITY STRUCTURE(S) (EG, JOINT SPACE, PERI-ARTICULAR TENDON[S], MUSCLE[S], NERVE[S], OTHER SOFT-TISSUE STRUCTURE[S], OR SOFT-TISSUE MASS[ES]), REAL-TIME WITH IMAGE DOCUMENTATION" 9514948_1 CDM 402 RC 76882 HCPCS outpatient 427 320.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 380.03 89 999999999 333.06 405.65 percent of total billed charges "ULTRASOUND, LIMITED, JOINT OR FOCAL EVALUATION OF OTHER NONVASCULAR EXTREMITY STRUCTURE(S) (EG, JOINT SPACE, PERI-ARTICULAR TENDON[S], MUSCLE[S], NERVE[S], OTHER SOFT-TISSUE STRUCTURE[S], OR SOFT-TISSUE MASS[ES]), REAL-TIME WITH IMAGE DOCUMENTATION" 9514948_1 CDM 402 RC 76882 HCPCS outpatient 427 320.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 375.76 88 999999999 333.06 405.65 percent of total billed charges "ULTRASOUND, LIMITED, JOINT OR FOCAL EVALUATION OF OTHER NONVASCULAR EXTREMITY STRUCTURE(S) (EG, JOINT SPACE, PERI-ARTICULAR TENDON[S], MUSCLE[S], NERVE[S], OTHER SOFT-TISSUE STRUCTURE[S], OR SOFT-TISSUE MASS[ES]), REAL-TIME WITH IMAGE DOCUMENTATION" 9514948_1 CDM 402 RC 76882 HCPCS outpatient 427 320.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 380.03 89 999999999 333.06 405.65 percent of total billed charges "ADVANCED LIFE SUPPORT, LEVEL 2 (ALS 2)" 9514955_1 CDM 542 RC A0433 HCPCS outpatient 1255 941.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1129.5 90 999999999 978.9 1192.25 percent of total billed charges "ADVANCED LIFE SUPPORT, LEVEL 2 (ALS 2)" 9514955_1 CDM 542 RC A0433 HCPCS outpatient 1255 941.25 AETNA MCR ADV AETNA MCR ADV 978.9 78 999999999 978.9 1192.25 percent of total billed charges "ADVANCED LIFE SUPPORT, LEVEL 2 (ALS 2)" 9514955_1 CDM 542 RC A0433 HCPCS outpatient 1255 941.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1099 87.57 999999999 978.9 1192.25 percent of total billed charges "ADVANCED LIFE SUPPORT, LEVEL 2 (ALS 2)" 9514955_1 CDM 542 RC A0433 HCPCS outpatient 1255 941.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 1067.63 85.07 999999999 978.9 1192.25 percent of total billed charges "ADVANCED LIFE SUPPORT, LEVEL 2 (ALS 2)" 9514955_1 CDM 542 RC A0433 HCPCS outpatient 1255 941.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1067.63 85.07 999999999 978.9 1192.25 percent of total billed charges "ADVANCED LIFE SUPPORT, LEVEL 2 (ALS 2)" 9514955_1 CDM 542 RC A0433 HCPCS outpatient 1255 941.25 MOLINA MCAID MOLINA MCAID 1046.67 83.4 999999999 978.9 1192.25 percent of total billed charges "ADVANCED LIFE SUPPORT, LEVEL 2 (ALS 2)" 9514955_1 CDM 542 RC A0433 HCPCS outpatient 1255 941.25 MOLINA MCR ADV MOLINA MCR ADV 1116.95 89 999999999 978.9 1192.25 percent of total billed charges "ADVANCED LIFE SUPPORT, LEVEL 2 (ALS 2)" 9514955_1 CDM 542 RC A0433 HCPCS outpatient 1255 941.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1116.95 89 999999999 978.9 1192.25 percent of total billed charges "ADVANCED LIFE SUPPORT, LEVEL 2 (ALS 2)" 9514955_1 CDM 542 RC A0433 HCPCS outpatient 1255 941.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1116.95 89 999999999 978.9 1192.25 percent of total billed charges "ADVANCED LIFE SUPPORT, LEVEL 2 (ALS 2)" 9514955_1 CDM 542 RC A0433 HCPCS outpatient 1255 941.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1129.5 90 999999999 978.9 1192.25 percent of total billed charges "ADVANCED LIFE SUPPORT, LEVEL 2 (ALS 2)" 9514955_1 CDM 542 RC A0433 HCPCS outpatient 1255 941.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1192.25 95 999999999 978.9 1192.25 percent of total billed charges "ADVANCED LIFE SUPPORT, LEVEL 2 (ALS 2)" 9514955_1 CDM 542 RC A0433 HCPCS outpatient 1255 941.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1192.25 95 999999999 978.9 1192.25 percent of total billed charges "ADVANCED LIFE SUPPORT, LEVEL 2 (ALS 2)" 9514955_1 CDM 542 RC A0433 HCPCS outpatient 1255 941.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1116.95 89 999999999 978.9 1192.25 percent of total billed charges "ADVANCED LIFE SUPPORT, LEVEL 2 (ALS 2)" 9514955_1 CDM 542 RC A0433 HCPCS outpatient 1255 941.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1104.4 88 999999999 978.9 1192.25 percent of total billed charges "ADVANCED LIFE SUPPORT, LEVEL 2 (ALS 2)" 9514955_1 CDM 542 RC A0433 HCPCS outpatient 1255 941.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1116.95 89 999999999 978.9 1192.25 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 9514996_1 CDM 361 RC 20550 HCPCS outpatient 535 401.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 481.5 999999999 417.3 508.25 case rate "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 9514996_1 CDM 361 RC 20550 HCPCS outpatient 535 401.25 AETNA MCR ADV AETNA MCR ADV 417.3 78 999999999 417.3 508.25 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 9514996_1 CDM 361 RC 20550 HCPCS outpatient 535 401.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 468.5 87.57 999999999 417.3 508.25 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 9514996_1 CDM 361 RC 20550 HCPCS outpatient 535 401.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 455.12 85.07 999999999 417.3 508.25 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 9514996_1 CDM 361 RC 20550 HCPCS outpatient 535 401.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 455.12 85.07 999999999 417.3 508.25 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 9514996_1 CDM 361 RC 20550 HCPCS outpatient 535 401.25 MOLINA MCAID MOLINA MCAID 446.19 83.4 999999999 417.3 508.25 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 9514996_1 CDM 361 RC 20550 HCPCS outpatient 535 401.25 MOLINA MCR ADV MOLINA MCR ADV 476.15 89 999999999 417.3 508.25 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 9514996_1 CDM 361 RC 20550 HCPCS outpatient 535 401.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 476.15 89 999999999 417.3 508.25 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 9514996_1 CDM 361 RC 20550 HCPCS outpatient 535 401.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 476.15 89 999999999 417.3 508.25 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 9514996_1 CDM 361 RC 20550 HCPCS outpatient 535 401.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 481.5 90 999999999 417.3 508.25 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 9514996_1 CDM 361 RC 20550 HCPCS outpatient 535 401.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 508.25 95 999999999 417.3 508.25 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 9514996_1 CDM 361 RC 20550 HCPCS outpatient 535 401.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 508.25 95 999999999 417.3 508.25 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 9514996_1 CDM 361 RC 20550 HCPCS outpatient 535 401.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 476.15 89 999999999 417.3 508.25 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 9514996_1 CDM 361 RC 20550 HCPCS outpatient 535 401.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 470.8 88 999999999 417.3 508.25 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 9514996_1 CDM 361 RC 20550 HCPCS outpatient 535 401.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 476.15 89 999999999 417.3 508.25 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 9514996_50_1 CDM 361 RC 20550 HCPCS outpatient 800 600 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 720 999999999 624 760 case rate "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 9514996_50_1 CDM 361 RC 20550 HCPCS outpatient 800 600 AETNA MCR ADV AETNA MCR ADV 50 624 78 999999999 624 760 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 9514996_50_1 CDM 361 RC 20550 HCPCS outpatient 800 600 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 700.56 87.57 999999999 624 760 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 9514996_50_1 CDM 361 RC 20550 HCPCS outpatient 800 600 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 680.56 85.07 999999999 624 760 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 9514996_50_1 CDM 361 RC 20550 HCPCS outpatient 800 600 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 680.56 85.07 999999999 624 760 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 9514996_50_1 CDM 361 RC 20550 HCPCS outpatient 800 600 MOLINA MCAID MOLINA MCAID 50 667.2 83.4 999999999 624 760 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 9514996_50_1 CDM 361 RC 20550 HCPCS outpatient 800 600 MOLINA MCR ADV MOLINA MCR ADV 50 712 89 999999999 624 760 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 9514996_50_1 CDM 361 RC 20550 HCPCS outpatient 800 600 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 712 89 999999999 624 760 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 9514996_50_1 CDM 361 RC 20550 HCPCS outpatient 800 600 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 712 89 999999999 624 760 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 9514996_50_1 CDM 361 RC 20550 HCPCS outpatient 800 600 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 720 90 999999999 624 760 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 9514996_50_1 CDM 361 RC 20550 HCPCS outpatient 800 600 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 760 95 999999999 624 760 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 9514996_50_1 CDM 361 RC 20550 HCPCS outpatient 800 600 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 760 95 999999999 624 760 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 9514996_50_1 CDM 361 RC 20550 HCPCS outpatient 800 600 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 712 89 999999999 624 760 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 9514996_50_1 CDM 361 RC 20550 HCPCS outpatient 800 600 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 704 88 999999999 624 760 percent of total billed charges "INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")" 9514996_50_1 CDM 361 RC 20550 HCPCS outpatient 800 600 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 712 89 999999999 624 760 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT" 9515012_1 CDM 361 RC 64633 HCPCS outpatient 2363 1772.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 2126.7 999999999 1843.14 2244.85 case rate "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT" 9515012_1 CDM 361 RC 64633 HCPCS outpatient 2363 1772.25 AETNA MCR ADV AETNA MCR ADV 1843.14 78 999999999 1843.14 2244.85 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT" 9515012_1 CDM 361 RC 64633 HCPCS outpatient 2363 1772.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 2069.28 87.57 999999999 1843.14 2244.85 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT" 9515012_1 CDM 361 RC 64633 HCPCS outpatient 2363 1772.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 2010.2 85.07 999999999 1843.14 2244.85 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT" 9515012_1 CDM 361 RC 64633 HCPCS outpatient 2363 1772.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 2010.2 85.07 999999999 1843.14 2244.85 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT" 9515012_1 CDM 361 RC 64633 HCPCS outpatient 2363 1772.25 MOLINA MCAID MOLINA MCAID 1970.74 83.4 999999999 1843.14 2244.85 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT" 9515012_1 CDM 361 RC 64633 HCPCS outpatient 2363 1772.25 MOLINA MCR ADV MOLINA MCR ADV 2103.07 89 999999999 1843.14 2244.85 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT" 9515012_1 CDM 361 RC 64633 HCPCS outpatient 2363 1772.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 2103.07 89 999999999 1843.14 2244.85 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT" 9515012_1 CDM 361 RC 64633 HCPCS outpatient 2363 1772.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 2103.07 89 999999999 1843.14 2244.85 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT" 9515012_1 CDM 361 RC 64633 HCPCS outpatient 2363 1772.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 2126.7 90 999999999 1843.14 2244.85 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT" 9515012_1 CDM 361 RC 64633 HCPCS outpatient 2363 1772.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 2244.85 95 999999999 1843.14 2244.85 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT" 9515012_1 CDM 361 RC 64633 HCPCS outpatient 2363 1772.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 2244.85 95 999999999 1843.14 2244.85 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT" 9515012_1 CDM 361 RC 64633 HCPCS outpatient 2363 1772.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 2103.07 89 999999999 1843.14 2244.85 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT" 9515012_1 CDM 361 RC 64633 HCPCS outpatient 2363 1772.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 2079.44 88 999999999 1843.14 2244.85 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT" 9515012_1 CDM 361 RC 64633 HCPCS outpatient 2363 1772.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 2103.07 89 999999999 1843.14 2244.85 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515013_1 CDM 490 RC 64634 HCPCS outpatient 1477 1107.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1329.3 999999999 1152.06 1403.15 case rate "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515013_1 CDM 490 RC 64634 HCPCS outpatient 1477 1107.75 AETNA MCR ADV AETNA MCR ADV 1152.06 78 999999999 1152.06 1403.15 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515013_1 CDM 490 RC 64634 HCPCS outpatient 1477 1107.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1293.41 87.57 999999999 1152.06 1403.15 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515013_1 CDM 490 RC 64634 HCPCS outpatient 1477 1107.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 1256.48 85.07 999999999 1152.06 1403.15 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515013_1 CDM 490 RC 64634 HCPCS outpatient 1477 1107.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1256.48 85.07 999999999 1152.06 1403.15 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515013_1 CDM 490 RC 64634 HCPCS outpatient 1477 1107.75 MOLINA MCAID MOLINA MCAID 1231.82 83.4 999999999 1152.06 1403.15 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515013_1 CDM 490 RC 64634 HCPCS outpatient 1477 1107.75 MOLINA MCR ADV MOLINA MCR ADV 1314.53 89 999999999 1152.06 1403.15 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515013_1 CDM 490 RC 64634 HCPCS outpatient 1477 1107.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1314.53 89 999999999 1152.06 1403.15 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515013_1 CDM 490 RC 64634 HCPCS outpatient 1477 1107.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1314.53 89 999999999 1152.06 1403.15 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515013_1 CDM 490 RC 64634 HCPCS outpatient 1477 1107.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1329.3 90 999999999 1152.06 1403.15 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515013_1 CDM 490 RC 64634 HCPCS outpatient 1477 1107.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1403.15 95 999999999 1152.06 1403.15 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515013_1 CDM 490 RC 64634 HCPCS outpatient 1477 1107.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1403.15 95 999999999 1152.06 1403.15 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515013_1 CDM 490 RC 64634 HCPCS outpatient 1477 1107.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1314.53 89 999999999 1152.06 1403.15 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515013_1 CDM 490 RC 64634 HCPCS outpatient 1477 1107.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1299.76 88 999999999 1152.06 1403.15 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515013_1 CDM 490 RC 64634 HCPCS outpatient 1477 1107.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1314.53 89 999999999 1152.06 1403.15 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_1 CDM 490 RC 64635 HCPCS outpatient 2854 2140.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 2568.6 999999999 2226.12 2711.3 case rate "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_1 CDM 490 RC 64635 HCPCS outpatient 2854 2140.5 AETNA MCR ADV AETNA MCR ADV 2226.12 78 999999999 2226.12 2711.3 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_1 CDM 490 RC 64635 HCPCS outpatient 2854 2140.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 2499.25 87.57 999999999 2226.12 2711.3 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_1 CDM 490 RC 64635 HCPCS outpatient 2854 2140.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 2427.9 85.07 999999999 2226.12 2711.3 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_1 CDM 490 RC 64635 HCPCS outpatient 2854 2140.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 2427.9 85.07 999999999 2226.12 2711.3 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_1 CDM 490 RC 64635 HCPCS outpatient 2854 2140.5 MOLINA MCAID MOLINA MCAID 2380.24 83.4 999999999 2226.12 2711.3 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_1 CDM 490 RC 64635 HCPCS outpatient 2854 2140.5 MOLINA MCR ADV MOLINA MCR ADV 2540.06 89 999999999 2226.12 2711.3 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_1 CDM 490 RC 64635 HCPCS outpatient 2854 2140.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 2540.06 89 999999999 2226.12 2711.3 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_1 CDM 490 RC 64635 HCPCS outpatient 2854 2140.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 2540.06 89 999999999 2226.12 2711.3 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_1 CDM 490 RC 64635 HCPCS outpatient 2854 2140.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 2568.6 90 999999999 2226.12 2711.3 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_1 CDM 490 RC 64635 HCPCS outpatient 2854 2140.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 2711.3 95 999999999 2226.12 2711.3 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_1 CDM 490 RC 64635 HCPCS outpatient 2854 2140.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 2711.3 95 999999999 2226.12 2711.3 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_1 CDM 490 RC 64635 HCPCS outpatient 2854 2140.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 2540.06 89 999999999 2226.12 2711.3 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_1 CDM 490 RC 64635 HCPCS outpatient 2854 2140.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 2511.52 88 999999999 2226.12 2711.3 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_1 CDM 490 RC 64635 HCPCS outpatient 2854 2140.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 2540.06 89 999999999 2226.12 2711.3 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_50 CDM 490 RC 64635 HCPCS inpatient 4278 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_50 CDM 490 RC 64635 HCPCS inpatient 4278 AETNA MCR ADV AETNA MCR ADV 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_50 CDM 490 RC 64635 HCPCS inpatient 4278 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_50 CDM 490 RC 64635 HCPCS inpatient 4278 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_50 CDM 490 RC 64635 HCPCS inpatient 4278 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_50 CDM 490 RC 64635 HCPCS inpatient 4278 MOLINA MCAID MOLINA MCAID 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_50 CDM 490 RC 64635 HCPCS inpatient 4278 MOLINA MCR ADV MOLINA MCR ADV 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_50 CDM 490 RC 64635 HCPCS inpatient 4278 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_50 CDM 490 RC 64635 HCPCS inpatient 4278 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_50 CDM 490 RC 64635 HCPCS inpatient 4278 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_50 CDM 490 RC 64635 HCPCS inpatient 4278 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_50 CDM 490 RC 64635 HCPCS inpatient 4278 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_50 CDM 490 RC 64635 HCPCS inpatient 4278 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_50 CDM 490 RC 64635 HCPCS inpatient 4278 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_50 CDM 490 RC 64635 HCPCS inpatient 4278 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_50_1 CDM 490 RC 64635 HCPCS outpatient 4278 3208.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 3850.2 999999999 3336.84 4064.1 case rate "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_50_1 CDM 490 RC 64635 HCPCS outpatient 4278 3208.5 AETNA MCR ADV AETNA MCR ADV 50 3336.84 78 999999999 3336.84 4064.1 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_50_1 CDM 490 RC 64635 HCPCS outpatient 4278 3208.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 3746.24 87.57 999999999 3336.84 4064.1 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_50_1 CDM 490 RC 64635 HCPCS outpatient 4278 3208.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 3639.29 85.07 999999999 3336.84 4064.1 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_50_1 CDM 490 RC 64635 HCPCS outpatient 4278 3208.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 3639.29 85.07 999999999 3336.84 4064.1 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_50_1 CDM 490 RC 64635 HCPCS outpatient 4278 3208.5 MOLINA MCAID MOLINA MCAID 50 3567.85 83.4 999999999 3336.84 4064.1 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_50_1 CDM 490 RC 64635 HCPCS outpatient 4278 3208.5 MOLINA MCR ADV MOLINA MCR ADV 50 3807.42 89 999999999 3336.84 4064.1 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_50_1 CDM 490 RC 64635 HCPCS outpatient 4278 3208.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 3807.42 89 999999999 3336.84 4064.1 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_50_1 CDM 490 RC 64635 HCPCS outpatient 4278 3208.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 3807.42 89 999999999 3336.84 4064.1 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_50_1 CDM 490 RC 64635 HCPCS outpatient 4278 3208.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 3850.2 90 999999999 3336.84 4064.1 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_50_1 CDM 490 RC 64635 HCPCS outpatient 4278 3208.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 4064.1 95 999999999 3336.84 4064.1 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_50_1 CDM 490 RC 64635 HCPCS outpatient 4278 3208.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 4064.1 95 999999999 3336.84 4064.1 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_50_1 CDM 490 RC 64635 HCPCS outpatient 4278 3208.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 3807.42 89 999999999 3336.84 4064.1 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_50_1 CDM 490 RC 64635 HCPCS outpatient 4278 3208.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 3764.64 88 999999999 3336.84 4064.1 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT" 9515014_50_1 CDM 490 RC 64635 HCPCS outpatient 4278 3208.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 3807.42 89 999999999 3336.84 4064.1 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_1 CDM 490 RC 64636 HCPCS outpatient 1210 907.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1089 999999999 943.8 1149.5 case rate "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_1 CDM 490 RC 64636 HCPCS outpatient 1210 907.5 AETNA MCR ADV AETNA MCR ADV 943.8 78 999999999 943.8 1149.5 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_1 CDM 490 RC 64636 HCPCS outpatient 1210 907.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1059.6 87.57 999999999 943.8 1149.5 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_1 CDM 490 RC 64636 HCPCS outpatient 1210 907.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 1029.35 85.07 999999999 943.8 1149.5 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_1 CDM 490 RC 64636 HCPCS outpatient 1210 907.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1029.35 85.07 999999999 943.8 1149.5 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_1 CDM 490 RC 64636 HCPCS outpatient 1210 907.5 MOLINA MCAID MOLINA MCAID 1009.14 83.4 999999999 943.8 1149.5 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_1 CDM 490 RC 64636 HCPCS outpatient 1210 907.5 MOLINA MCR ADV MOLINA MCR ADV 1076.9 89 999999999 943.8 1149.5 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_1 CDM 490 RC 64636 HCPCS outpatient 1210 907.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1076.9 89 999999999 943.8 1149.5 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_1 CDM 490 RC 64636 HCPCS outpatient 1210 907.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1076.9 89 999999999 943.8 1149.5 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_1 CDM 490 RC 64636 HCPCS outpatient 1210 907.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1089 90 999999999 943.8 1149.5 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_1 CDM 490 RC 64636 HCPCS outpatient 1210 907.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1149.5 95 999999999 943.8 1149.5 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_1 CDM 490 RC 64636 HCPCS outpatient 1210 907.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1149.5 95 999999999 943.8 1149.5 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_1 CDM 490 RC 64636 HCPCS outpatient 1210 907.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1076.9 89 999999999 943.8 1149.5 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_1 CDM 490 RC 64636 HCPCS outpatient 1210 907.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1064.8 88 999999999 943.8 1149.5 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_1 CDM 490 RC 64636 HCPCS outpatient 1210 907.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1076.9 89 999999999 943.8 1149.5 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_50 CDM 490 RC 64636 HCPCS inpatient 1815 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_50 CDM 490 RC 64636 HCPCS inpatient 1815 AETNA MCR ADV AETNA MCR ADV 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_50 CDM 490 RC 64636 HCPCS inpatient 1815 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_50 CDM 490 RC 64636 HCPCS inpatient 1815 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_50 CDM 490 RC 64636 HCPCS inpatient 1815 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_50 CDM 490 RC 64636 HCPCS inpatient 1815 MOLINA MCAID MOLINA MCAID 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_50 CDM 490 RC 64636 HCPCS inpatient 1815 MOLINA MCR ADV MOLINA MCR ADV 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_50 CDM 490 RC 64636 HCPCS inpatient 1815 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_50 CDM 490 RC 64636 HCPCS inpatient 1815 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_50 CDM 490 RC 64636 HCPCS inpatient 1815 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_50 CDM 490 RC 64636 HCPCS inpatient 1815 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_50 CDM 490 RC 64636 HCPCS inpatient 1815 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_50 CDM 490 RC 64636 HCPCS inpatient 1815 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_50 CDM 490 RC 64636 HCPCS inpatient 1815 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_50 CDM 490 RC 64636 HCPCS inpatient 1815 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_50_1 CDM 490 RC 64636 HCPCS outpatient 1815 1361.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 1633.5 999999999 1415.7 1724.25 case rate "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_50_1 CDM 490 RC 64636 HCPCS outpatient 1815 1361.25 AETNA MCR ADV AETNA MCR ADV 50 1415.7 78 999999999 1415.7 1724.25 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_50_1 CDM 490 RC 64636 HCPCS outpatient 1815 1361.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 1589.4 87.57 999999999 1415.7 1724.25 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_50_1 CDM 490 RC 64636 HCPCS outpatient 1815 1361.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 1544.02 85.07 999999999 1415.7 1724.25 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_50_1 CDM 490 RC 64636 HCPCS outpatient 1815 1361.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 1544.02 85.07 999999999 1415.7 1724.25 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_50_1 CDM 490 RC 64636 HCPCS outpatient 1815 1361.25 MOLINA MCAID MOLINA MCAID 50 1513.71 83.4 999999999 1415.7 1724.25 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_50_1 CDM 490 RC 64636 HCPCS outpatient 1815 1361.25 MOLINA MCR ADV MOLINA MCR ADV 50 1615.35 89 999999999 1415.7 1724.25 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_50_1 CDM 490 RC 64636 HCPCS outpatient 1815 1361.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 1615.35 89 999999999 1415.7 1724.25 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_50_1 CDM 490 RC 64636 HCPCS outpatient 1815 1361.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 1615.35 89 999999999 1415.7 1724.25 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_50_1 CDM 490 RC 64636 HCPCS outpatient 1815 1361.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 1633.5 90 999999999 1415.7 1724.25 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_50_1 CDM 490 RC 64636 HCPCS outpatient 1815 1361.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 1724.25 95 999999999 1415.7 1724.25 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_50_1 CDM 490 RC 64636 HCPCS outpatient 1815 1361.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 1724.25 95 999999999 1415.7 1724.25 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_50_1 CDM 490 RC 64636 HCPCS outpatient 1815 1361.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 1615.35 89 999999999 1415.7 1724.25 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_50_1 CDM 490 RC 64636 HCPCS outpatient 1815 1361.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 1597.2 88 999999999 1415.7 1724.25 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515015_50_1 CDM 490 RC 64636 HCPCS outpatient 1815 1361.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 1615.35 89 999999999 1415.7 1724.25 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT" 9515092_1 CDM 730 RC 93005 HCPCS outpatient 228 171 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 205.2 90 999999999 177.84 216.6 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT" 9515092_1 CDM 730 RC 93005 HCPCS outpatient 228 171 AETNA MCR ADV AETNA MCR ADV 177.84 78 999999999 177.84 216.6 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT" 9515092_1 CDM 730 RC 93005 HCPCS outpatient 228 171 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 199.66 87.57 999999999 177.84 216.6 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT" 9515092_1 CDM 730 RC 93005 HCPCS outpatient 228 171 COORDINATED CARE MCAID COORDINATED CARE MCAID 193.96 85.07 999999999 177.84 216.6 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT" 9515092_1 CDM 730 RC 93005 HCPCS outpatient 228 171 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 193.96 85.07 999999999 177.84 216.6 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT" 9515092_1 CDM 730 RC 93005 HCPCS outpatient 228 171 MOLINA MCAID MOLINA MCAID 190.15 83.4 999999999 177.84 216.6 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT" 9515092_1 CDM 730 RC 93005 HCPCS outpatient 228 171 MOLINA MCR ADV MOLINA MCR ADV 202.92 89 999999999 177.84 216.6 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT" 9515092_1 CDM 730 RC 93005 HCPCS outpatient 228 171 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 202.92 89 999999999 177.84 216.6 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT" 9515092_1 CDM 730 RC 93005 HCPCS outpatient 228 171 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 202.92 89 999999999 177.84 216.6 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT" 9515092_1 CDM 730 RC 93005 HCPCS outpatient 228 171 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 205.2 90 999999999 177.84 216.6 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT" 9515092_1 CDM 730 RC 93005 HCPCS outpatient 228 171 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 216.6 95 999999999 177.84 216.6 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT" 9515092_1 CDM 730 RC 93005 HCPCS outpatient 228 171 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 216.6 95 999999999 177.84 216.6 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT" 9515092_1 CDM 730 RC 93005 HCPCS outpatient 228 171 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 202.92 89 999999999 177.84 216.6 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT" 9515092_1 CDM 730 RC 93005 HCPCS outpatient 228 171 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 200.64 88 999999999 177.84 216.6 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT" 9515092_1 CDM 730 RC 93005 HCPCS outpatient 228 171 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 202.92 89 999999999 177.84 216.6 percent of total billed charges "THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE" 9515142_1 CDM 361 RC 32554 HCPCS outpatient 1676 1257 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1508.4 999999999 1307.28 1592.2 case rate "THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE" 9515142_1 CDM 361 RC 32554 HCPCS outpatient 1676 1257 AETNA MCR ADV AETNA MCR ADV 1307.28 78 999999999 1307.28 1592.2 percent of total billed charges "THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE" 9515142_1 CDM 361 RC 32554 HCPCS outpatient 1676 1257 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1467.67 87.57 999999999 1307.28 1592.2 percent of total billed charges "THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE" 9515142_1 CDM 361 RC 32554 HCPCS outpatient 1676 1257 COORDINATED CARE MCAID COORDINATED CARE MCAID 1425.77 85.07 999999999 1307.28 1592.2 percent of total billed charges "THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE" 9515142_1 CDM 361 RC 32554 HCPCS outpatient 1676 1257 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1425.77 85.07 999999999 1307.28 1592.2 percent of total billed charges "THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE" 9515142_1 CDM 361 RC 32554 HCPCS outpatient 1676 1257 MOLINA MCAID MOLINA MCAID 1397.78 83.4 999999999 1307.28 1592.2 percent of total billed charges "THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE" 9515142_1 CDM 361 RC 32554 HCPCS outpatient 1676 1257 MOLINA MCR ADV MOLINA MCR ADV 1491.64 89 999999999 1307.28 1592.2 percent of total billed charges "THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE" 9515142_1 CDM 361 RC 32554 HCPCS outpatient 1676 1257 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1491.64 89 999999999 1307.28 1592.2 percent of total billed charges "THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE" 9515142_1 CDM 361 RC 32554 HCPCS outpatient 1676 1257 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1491.64 89 999999999 1307.28 1592.2 percent of total billed charges "THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE" 9515142_1 CDM 361 RC 32554 HCPCS outpatient 1676 1257 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1508.4 90 999999999 1307.28 1592.2 percent of total billed charges "THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE" 9515142_1 CDM 361 RC 32554 HCPCS outpatient 1676 1257 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1592.2 95 999999999 1307.28 1592.2 percent of total billed charges "THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE" 9515142_1 CDM 361 RC 32554 HCPCS outpatient 1676 1257 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1592.2 95 999999999 1307.28 1592.2 percent of total billed charges "THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE" 9515142_1 CDM 361 RC 32554 HCPCS outpatient 1676 1257 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1491.64 89 999999999 1307.28 1592.2 percent of total billed charges "THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE" 9515142_1 CDM 361 RC 32554 HCPCS outpatient 1676 1257 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1474.88 88 999999999 1307.28 1592.2 percent of total billed charges "THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE" 9515142_1 CDM 361 RC 32554 HCPCS outpatient 1676 1257 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1491.64 89 999999999 1307.28 1592.2 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 4 OR 5 VIEWS" 9515207_1 CDM 320 RC 72050 HCPCS outpatient 504 378 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 453.6 90 999999999 393.12 478.8 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 4 OR 5 VIEWS" 9515207_1 CDM 320 RC 72050 HCPCS outpatient 504 378 AETNA MCR ADV AETNA MCR ADV 393.12 78 999999999 393.12 478.8 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 4 OR 5 VIEWS" 9515207_1 CDM 320 RC 72050 HCPCS outpatient 504 378 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 441.35 87.57 999999999 393.12 478.8 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 4 OR 5 VIEWS" 9515207_1 CDM 320 RC 72050 HCPCS outpatient 504 378 COORDINATED CARE MCAID COORDINATED CARE MCAID 428.75 85.07 999999999 393.12 478.8 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 4 OR 5 VIEWS" 9515207_1 CDM 320 RC 72050 HCPCS outpatient 504 378 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 428.75 85.07 999999999 393.12 478.8 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 4 OR 5 VIEWS" 9515207_1 CDM 320 RC 72050 HCPCS outpatient 504 378 MOLINA MCAID MOLINA MCAID 420.34 83.4 999999999 393.12 478.8 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 4 OR 5 VIEWS" 9515207_1 CDM 320 RC 72050 HCPCS outpatient 504 378 MOLINA MCR ADV MOLINA MCR ADV 448.56 89 999999999 393.12 478.8 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 4 OR 5 VIEWS" 9515207_1 CDM 320 RC 72050 HCPCS outpatient 504 378 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 448.56 89 999999999 393.12 478.8 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 4 OR 5 VIEWS" 9515207_1 CDM 320 RC 72050 HCPCS outpatient 504 378 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 448.56 89 999999999 393.12 478.8 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 4 OR 5 VIEWS" 9515207_1 CDM 320 RC 72050 HCPCS outpatient 504 378 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 453.6 90 999999999 393.12 478.8 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 4 OR 5 VIEWS" 9515207_1 CDM 320 RC 72050 HCPCS outpatient 504 378 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 478.8 95 999999999 393.12 478.8 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 4 OR 5 VIEWS" 9515207_1 CDM 320 RC 72050 HCPCS outpatient 504 378 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 478.8 95 999999999 393.12 478.8 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 4 OR 5 VIEWS" 9515207_1 CDM 320 RC 72050 HCPCS outpatient 504 378 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 448.56 89 999999999 393.12 478.8 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 4 OR 5 VIEWS" 9515207_1 CDM 320 RC 72050 HCPCS outpatient 504 378 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 443.52 88 999999999 393.12 478.8 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 4 OR 5 VIEWS" 9515207_1 CDM 320 RC 72050 HCPCS outpatient 504 378 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 448.56 89 999999999 393.12 478.8 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 6 OR MORE VIEWS" 9515208_1 CDM 320 RC 72052 HCPCS outpatient 640 480 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 576 90 999999999 499.2 608 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 6 OR MORE VIEWS" 9515208_1 CDM 320 RC 72052 HCPCS outpatient 640 480 AETNA MCR ADV AETNA MCR ADV 499.2 78 999999999 499.2 608 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 6 OR MORE VIEWS" 9515208_1 CDM 320 RC 72052 HCPCS outpatient 640 480 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 560.45 87.57 999999999 499.2 608 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 6 OR MORE VIEWS" 9515208_1 CDM 320 RC 72052 HCPCS outpatient 640 480 COORDINATED CARE MCAID COORDINATED CARE MCAID 544.45 85.07 999999999 499.2 608 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 6 OR MORE VIEWS" 9515208_1 CDM 320 RC 72052 HCPCS outpatient 640 480 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 544.45 85.07 999999999 499.2 608 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 6 OR MORE VIEWS" 9515208_1 CDM 320 RC 72052 HCPCS outpatient 640 480 MOLINA MCAID MOLINA MCAID 533.76 83.4 999999999 499.2 608 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 6 OR MORE VIEWS" 9515208_1 CDM 320 RC 72052 HCPCS outpatient 640 480 MOLINA MCR ADV MOLINA MCR ADV 569.6 89 999999999 499.2 608 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 6 OR MORE VIEWS" 9515208_1 CDM 320 RC 72052 HCPCS outpatient 640 480 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 569.6 89 999999999 499.2 608 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 6 OR MORE VIEWS" 9515208_1 CDM 320 RC 72052 HCPCS outpatient 640 480 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 569.6 89 999999999 499.2 608 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 6 OR MORE VIEWS" 9515208_1 CDM 320 RC 72052 HCPCS outpatient 640 480 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 576 90 999999999 499.2 608 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 6 OR MORE VIEWS" 9515208_1 CDM 320 RC 72052 HCPCS outpatient 640 480 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 608 95 999999999 499.2 608 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 6 OR MORE VIEWS" 9515208_1 CDM 320 RC 72052 HCPCS outpatient 640 480 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 608 95 999999999 499.2 608 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 6 OR MORE VIEWS" 9515208_1 CDM 320 RC 72052 HCPCS outpatient 640 480 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 569.6 89 999999999 499.2 608 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 6 OR MORE VIEWS" 9515208_1 CDM 320 RC 72052 HCPCS outpatient 640 480 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 563.2 88 999999999 499.2 608 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 6 OR MORE VIEWS" 9515208_1 CDM 320 RC 72052 HCPCS outpatient 640 480 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 569.6 89 999999999 499.2 608 percent of total billed charges "EVALUATION OF SPEECH FLUENCY (EG, STUTTERING, CLUTTERING)" 9515337_1 CDM 444 RC 92521 HCPCS outpatient 401 300.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 360.9 90 999999999 312.78 380.95 percent of total billed charges "EVALUATION OF SPEECH FLUENCY (EG, STUTTERING, CLUTTERING)" 9515337_1 CDM 444 RC 92521 HCPCS outpatient 401 300.75 AETNA MCR ADV AETNA MCR ADV 312.78 78 999999999 312.78 380.95 percent of total billed charges "EVALUATION OF SPEECH FLUENCY (EG, STUTTERING, CLUTTERING)" 9515337_1 CDM 444 RC 92521 HCPCS outpatient 401 300.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 351.16 87.57 999999999 312.78 380.95 percent of total billed charges "EVALUATION OF SPEECH FLUENCY (EG, STUTTERING, CLUTTERING)" 9515337_1 CDM 444 RC 92521 HCPCS outpatient 401 300.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 341.13 85.07 999999999 312.78 380.95 percent of total billed charges "EVALUATION OF SPEECH FLUENCY (EG, STUTTERING, CLUTTERING)" 9515337_1 CDM 444 RC 92521 HCPCS outpatient 401 300.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 341.13 85.07 999999999 312.78 380.95 percent of total billed charges "EVALUATION OF SPEECH FLUENCY (EG, STUTTERING, CLUTTERING)" 9515337_1 CDM 444 RC 92521 HCPCS outpatient 401 300.75 MOLINA MCAID MOLINA MCAID 334.43 83.4 999999999 312.78 380.95 percent of total billed charges "EVALUATION OF SPEECH FLUENCY (EG, STUTTERING, CLUTTERING)" 9515337_1 CDM 444 RC 92521 HCPCS outpatient 401 300.75 MOLINA MCR ADV MOLINA MCR ADV 356.89 89 999999999 312.78 380.95 percent of total billed charges "EVALUATION OF SPEECH FLUENCY (EG, STUTTERING, CLUTTERING)" 9515337_1 CDM 444 RC 92521 HCPCS outpatient 401 300.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 356.89 89 999999999 312.78 380.95 percent of total billed charges "EVALUATION OF SPEECH FLUENCY (EG, STUTTERING, CLUTTERING)" 9515337_1 CDM 444 RC 92521 HCPCS outpatient 401 300.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 356.89 89 999999999 312.78 380.95 percent of total billed charges "EVALUATION OF SPEECH FLUENCY (EG, STUTTERING, CLUTTERING)" 9515337_1 CDM 444 RC 92521 HCPCS outpatient 401 300.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 360.9 90 999999999 312.78 380.95 percent of total billed charges "EVALUATION OF SPEECH FLUENCY (EG, STUTTERING, CLUTTERING)" 9515337_1 CDM 444 RC 92521 HCPCS outpatient 401 300.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 380.95 95 999999999 312.78 380.95 percent of total billed charges "EVALUATION OF SPEECH FLUENCY (EG, STUTTERING, CLUTTERING)" 9515337_1 CDM 444 RC 92521 HCPCS outpatient 401 300.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 380.95 95 999999999 312.78 380.95 percent of total billed charges "EVALUATION OF SPEECH FLUENCY (EG, STUTTERING, CLUTTERING)" 9515337_1 CDM 444 RC 92521 HCPCS outpatient 401 300.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 356.89 89 999999999 312.78 380.95 percent of total billed charges "EVALUATION OF SPEECH FLUENCY (EG, STUTTERING, CLUTTERING)" 9515337_1 CDM 444 RC 92521 HCPCS outpatient 401 300.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 352.88 88 999999999 312.78 380.95 percent of total billed charges "EVALUATION OF SPEECH FLUENCY (EG, STUTTERING, CLUTTERING)" 9515337_1 CDM 444 RC 92521 HCPCS outpatient 401 300.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 356.89 89 999999999 312.78 380.95 percent of total billed charges "EVALUATION OF SPEECH SOUND PRODUCTION (EG, ARTICULATION, PHONOLOGICAL PROCESS, APRAXIA, DYSARTHRIA)" 9515338_1 CDM 444 RC 92522 HCPCS outpatient 348 261 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 313.2 90 999999999 271.44 330.6 percent of total billed charges "EVALUATION OF SPEECH SOUND PRODUCTION (EG, ARTICULATION, PHONOLOGICAL PROCESS, APRAXIA, DYSARTHRIA)" 9515338_1 CDM 444 RC 92522 HCPCS outpatient 348 261 AETNA MCR ADV AETNA MCR ADV 271.44 78 999999999 271.44 330.6 percent of total billed charges "EVALUATION OF SPEECH SOUND PRODUCTION (EG, ARTICULATION, PHONOLOGICAL PROCESS, APRAXIA, DYSARTHRIA)" 9515338_1 CDM 444 RC 92522 HCPCS outpatient 348 261 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 304.74 87.57 999999999 271.44 330.6 percent of total billed charges "EVALUATION OF SPEECH SOUND PRODUCTION (EG, ARTICULATION, PHONOLOGICAL PROCESS, APRAXIA, DYSARTHRIA)" 9515338_1 CDM 444 RC 92522 HCPCS outpatient 348 261 COORDINATED CARE MCAID COORDINATED CARE MCAID 296.04 85.07 999999999 271.44 330.6 percent of total billed charges "EVALUATION OF SPEECH SOUND PRODUCTION (EG, ARTICULATION, PHONOLOGICAL PROCESS, APRAXIA, DYSARTHRIA)" 9515338_1 CDM 444 RC 92522 HCPCS outpatient 348 261 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 296.04 85.07 999999999 271.44 330.6 percent of total billed charges "EVALUATION OF SPEECH SOUND PRODUCTION (EG, ARTICULATION, PHONOLOGICAL PROCESS, APRAXIA, DYSARTHRIA)" 9515338_1 CDM 444 RC 92522 HCPCS outpatient 348 261 MOLINA MCAID MOLINA MCAID 290.23 83.4 999999999 271.44 330.6 percent of total billed charges "EVALUATION OF SPEECH SOUND PRODUCTION (EG, ARTICULATION, PHONOLOGICAL PROCESS, APRAXIA, DYSARTHRIA)" 9515338_1 CDM 444 RC 92522 HCPCS outpatient 348 261 MOLINA MCR ADV MOLINA MCR ADV 309.72 89 999999999 271.44 330.6 percent of total billed charges "EVALUATION OF SPEECH SOUND PRODUCTION (EG, ARTICULATION, PHONOLOGICAL PROCESS, APRAXIA, DYSARTHRIA)" 9515338_1 CDM 444 RC 92522 HCPCS outpatient 348 261 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 309.72 89 999999999 271.44 330.6 percent of total billed charges "EVALUATION OF SPEECH SOUND PRODUCTION (EG, ARTICULATION, PHONOLOGICAL PROCESS, APRAXIA, DYSARTHRIA)" 9515338_1 CDM 444 RC 92522 HCPCS outpatient 348 261 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 309.72 89 999999999 271.44 330.6 percent of total billed charges "EVALUATION OF SPEECH SOUND PRODUCTION (EG, ARTICULATION, PHONOLOGICAL PROCESS, APRAXIA, DYSARTHRIA)" 9515338_1 CDM 444 RC 92522 HCPCS outpatient 348 261 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 313.2 90 999999999 271.44 330.6 percent of total billed charges "EVALUATION OF SPEECH SOUND PRODUCTION (EG, ARTICULATION, PHONOLOGICAL PROCESS, APRAXIA, DYSARTHRIA)" 9515338_1 CDM 444 RC 92522 HCPCS outpatient 348 261 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 330.6 95 999999999 271.44 330.6 percent of total billed charges "EVALUATION OF SPEECH SOUND PRODUCTION (EG, ARTICULATION, PHONOLOGICAL PROCESS, APRAXIA, DYSARTHRIA)" 9515338_1 CDM 444 RC 92522 HCPCS outpatient 348 261 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 330.6 95 999999999 271.44 330.6 percent of total billed charges "EVALUATION OF SPEECH SOUND PRODUCTION (EG, ARTICULATION, PHONOLOGICAL PROCESS, APRAXIA, DYSARTHRIA)" 9515338_1 CDM 444 RC 92522 HCPCS outpatient 348 261 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 309.72 89 999999999 271.44 330.6 percent of total billed charges "EVALUATION OF SPEECH SOUND PRODUCTION (EG, ARTICULATION, PHONOLOGICAL PROCESS, APRAXIA, DYSARTHRIA)" 9515338_1 CDM 444 RC 92522 HCPCS outpatient 348 261 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 306.24 88 999999999 271.44 330.6 percent of total billed charges "EVALUATION OF SPEECH SOUND PRODUCTION (EG, ARTICULATION, PHONOLOGICAL PROCESS, APRAXIA, DYSARTHRIA)" 9515338_1 CDM 444 RC 92522 HCPCS outpatient 348 261 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 309.72 89 999999999 271.44 330.6 percent of total billed charges "EVALUATION OF SPEECH SOUND PRODUCTION (EG, ARTICULATION, PHONOLOGICAL PROCESS, APRAXIA, DYSARTHRIA); WITH EVALUATION OF LANGUAGE COMPREHENSION AND EXPRESSION (EG, RECEPTIVE AND EXPRESSIVE LANGUAGE)" 9515339_1 CDM 444 RC 92523 HCPCS outpatient 378 283.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 340.2 90 999999999 294.84 359.1 percent of total billed charges "EVALUATION OF SPEECH SOUND PRODUCTION (EG, ARTICULATION, PHONOLOGICAL PROCESS, APRAXIA, DYSARTHRIA); WITH EVALUATION OF LANGUAGE COMPREHENSION AND EXPRESSION (EG, RECEPTIVE AND EXPRESSIVE LANGUAGE)" 9515339_1 CDM 444 RC 92523 HCPCS outpatient 378 283.5 AETNA MCR ADV AETNA MCR ADV 294.84 78 999999999 294.84 359.1 percent of total billed charges "EVALUATION OF SPEECH SOUND PRODUCTION (EG, ARTICULATION, PHONOLOGICAL PROCESS, APRAXIA, DYSARTHRIA); WITH EVALUATION OF LANGUAGE COMPREHENSION AND EXPRESSION (EG, RECEPTIVE AND EXPRESSIVE LANGUAGE)" 9515339_1 CDM 444 RC 92523 HCPCS outpatient 378 283.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 331.01 87.57 999999999 294.84 359.1 percent of total billed charges "EVALUATION OF SPEECH SOUND PRODUCTION (EG, ARTICULATION, PHONOLOGICAL PROCESS, APRAXIA, DYSARTHRIA); WITH EVALUATION OF LANGUAGE COMPREHENSION AND EXPRESSION (EG, RECEPTIVE AND EXPRESSIVE LANGUAGE)" 9515339_1 CDM 444 RC 92523 HCPCS outpatient 378 283.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 321.56 85.07 999999999 294.84 359.1 percent of total billed charges "EVALUATION OF SPEECH SOUND PRODUCTION (EG, ARTICULATION, PHONOLOGICAL PROCESS, APRAXIA, DYSARTHRIA); WITH EVALUATION OF LANGUAGE COMPREHENSION AND EXPRESSION (EG, RECEPTIVE AND EXPRESSIVE LANGUAGE)" 9515339_1 CDM 444 RC 92523 HCPCS outpatient 378 283.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 321.56 85.07 999999999 294.84 359.1 percent of total billed charges "EVALUATION OF SPEECH SOUND PRODUCTION (EG, ARTICULATION, PHONOLOGICAL PROCESS, APRAXIA, DYSARTHRIA); WITH EVALUATION OF LANGUAGE COMPREHENSION AND EXPRESSION (EG, RECEPTIVE AND EXPRESSIVE LANGUAGE)" 9515339_1 CDM 444 RC 92523 HCPCS outpatient 378 283.5 MOLINA MCAID MOLINA MCAID 315.25 83.4 999999999 294.84 359.1 percent of total billed charges "EVALUATION OF SPEECH SOUND PRODUCTION (EG, ARTICULATION, PHONOLOGICAL PROCESS, APRAXIA, DYSARTHRIA); WITH EVALUATION OF LANGUAGE COMPREHENSION AND EXPRESSION (EG, RECEPTIVE AND EXPRESSIVE LANGUAGE)" 9515339_1 CDM 444 RC 92523 HCPCS outpatient 378 283.5 MOLINA MCR ADV MOLINA MCR ADV 336.42 89 999999999 294.84 359.1 percent of total billed charges "EVALUATION OF SPEECH SOUND PRODUCTION (EG, ARTICULATION, PHONOLOGICAL PROCESS, APRAXIA, DYSARTHRIA); WITH EVALUATION OF LANGUAGE COMPREHENSION AND EXPRESSION (EG, RECEPTIVE AND EXPRESSIVE LANGUAGE)" 9515339_1 CDM 444 RC 92523 HCPCS outpatient 378 283.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 336.42 89 999999999 294.84 359.1 percent of total billed charges "EVALUATION OF SPEECH SOUND PRODUCTION (EG, ARTICULATION, PHONOLOGICAL PROCESS, APRAXIA, DYSARTHRIA); WITH EVALUATION OF LANGUAGE COMPREHENSION AND EXPRESSION (EG, RECEPTIVE AND EXPRESSIVE LANGUAGE)" 9515339_1 CDM 444 RC 92523 HCPCS outpatient 378 283.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 336.42 89 999999999 294.84 359.1 percent of total billed charges "EVALUATION OF SPEECH SOUND PRODUCTION (EG, ARTICULATION, PHONOLOGICAL PROCESS, APRAXIA, DYSARTHRIA); WITH EVALUATION OF LANGUAGE COMPREHENSION AND EXPRESSION (EG, RECEPTIVE AND EXPRESSIVE LANGUAGE)" 9515339_1 CDM 444 RC 92523 HCPCS outpatient 378 283.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 340.2 90 999999999 294.84 359.1 percent of total billed charges "EVALUATION OF SPEECH SOUND PRODUCTION (EG, ARTICULATION, PHONOLOGICAL PROCESS, APRAXIA, DYSARTHRIA); WITH EVALUATION OF LANGUAGE COMPREHENSION AND EXPRESSION (EG, RECEPTIVE AND EXPRESSIVE LANGUAGE)" 9515339_1 CDM 444 RC 92523 HCPCS outpatient 378 283.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 359.1 95 999999999 294.84 359.1 percent of total billed charges "EVALUATION OF SPEECH SOUND PRODUCTION (EG, ARTICULATION, PHONOLOGICAL PROCESS, APRAXIA, DYSARTHRIA); WITH EVALUATION OF LANGUAGE COMPREHENSION AND EXPRESSION (EG, RECEPTIVE AND EXPRESSIVE LANGUAGE)" 9515339_1 CDM 444 RC 92523 HCPCS outpatient 378 283.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 359.1 95 999999999 294.84 359.1 percent of total billed charges "EVALUATION OF SPEECH SOUND PRODUCTION (EG, ARTICULATION, PHONOLOGICAL PROCESS, APRAXIA, DYSARTHRIA); WITH EVALUATION OF LANGUAGE COMPREHENSION AND EXPRESSION (EG, RECEPTIVE AND EXPRESSIVE LANGUAGE)" 9515339_1 CDM 444 RC 92523 HCPCS outpatient 378 283.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 336.42 89 999999999 294.84 359.1 percent of total billed charges "EVALUATION OF SPEECH SOUND PRODUCTION (EG, ARTICULATION, PHONOLOGICAL PROCESS, APRAXIA, DYSARTHRIA); WITH EVALUATION OF LANGUAGE COMPREHENSION AND EXPRESSION (EG, RECEPTIVE AND EXPRESSIVE LANGUAGE)" 9515339_1 CDM 444 RC 92523 HCPCS outpatient 378 283.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 332.64 88 999999999 294.84 359.1 percent of total billed charges "EVALUATION OF SPEECH SOUND PRODUCTION (EG, ARTICULATION, PHONOLOGICAL PROCESS, APRAXIA, DYSARTHRIA); WITH EVALUATION OF LANGUAGE COMPREHENSION AND EXPRESSION (EG, RECEPTIVE AND EXPRESSIVE LANGUAGE)" 9515339_1 CDM 444 RC 92523 HCPCS outpatient 378 283.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 336.42 89 999999999 294.84 359.1 percent of total billed charges BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE 9515340_1 CDM 444 RC 92524 HCPCS outpatient 354 265.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 318.6 90 999999999 276.12 336.3 percent of total billed charges BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE 9515340_1 CDM 444 RC 92524 HCPCS outpatient 354 265.5 AETNA MCR ADV AETNA MCR ADV 276.12 78 999999999 276.12 336.3 percent of total billed charges BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE 9515340_1 CDM 444 RC 92524 HCPCS outpatient 354 265.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 310 87.57 999999999 276.12 336.3 percent of total billed charges BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE 9515340_1 CDM 444 RC 92524 HCPCS outpatient 354 265.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 301.15 85.07 999999999 276.12 336.3 percent of total billed charges BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE 9515340_1 CDM 444 RC 92524 HCPCS outpatient 354 265.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 301.15 85.07 999999999 276.12 336.3 percent of total billed charges BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE 9515340_1 CDM 444 RC 92524 HCPCS outpatient 354 265.5 MOLINA MCAID MOLINA MCAID 295.24 83.4 999999999 276.12 336.3 percent of total billed charges BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE 9515340_1 CDM 444 RC 92524 HCPCS outpatient 354 265.5 MOLINA MCR ADV MOLINA MCR ADV 315.06 89 999999999 276.12 336.3 percent of total billed charges BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE 9515340_1 CDM 444 RC 92524 HCPCS outpatient 354 265.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 315.06 89 999999999 276.12 336.3 percent of total billed charges BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE 9515340_1 CDM 444 RC 92524 HCPCS outpatient 354 265.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 315.06 89 999999999 276.12 336.3 percent of total billed charges BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE 9515340_1 CDM 444 RC 92524 HCPCS outpatient 354 265.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 318.6 90 999999999 276.12 336.3 percent of total billed charges BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE 9515340_1 CDM 444 RC 92524 HCPCS outpatient 354 265.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 336.3 95 999999999 276.12 336.3 percent of total billed charges BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE 9515340_1 CDM 444 RC 92524 HCPCS outpatient 354 265.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 336.3 95 999999999 276.12 336.3 percent of total billed charges BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE 9515340_1 CDM 444 RC 92524 HCPCS outpatient 354 265.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 315.06 89 999999999 276.12 336.3 percent of total billed charges BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE 9515340_1 CDM 444 RC 92524 HCPCS outpatient 354 265.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 311.52 88 999999999 276.12 336.3 percent of total billed charges BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE 9515340_1 CDM 444 RC 92524 HCPCS outpatient 354 265.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 315.06 89 999999999 276.12 336.3 percent of total billed charges "UNLISTED PROCEDURE, NERVOUS SYSTEM" 9515411_1 CDM 361 RC 64999 HCPCS outpatient 1586 1189.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1427.4 999999999 1237.08 1506.7 case rate "UNLISTED PROCEDURE, NERVOUS SYSTEM" 9515411_1 CDM 361 RC 64999 HCPCS outpatient 1586 1189.5 AETNA MCR ADV AETNA MCR ADV 1237.08 78 999999999 1237.08 1506.7 percent of total billed charges "UNLISTED PROCEDURE, NERVOUS SYSTEM" 9515411_1 CDM 361 RC 64999 HCPCS outpatient 1586 1189.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1388.86 87.57 999999999 1237.08 1506.7 percent of total billed charges "UNLISTED PROCEDURE, NERVOUS SYSTEM" 9515411_1 CDM 361 RC 64999 HCPCS outpatient 1586 1189.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 1349.21 85.07 999999999 1237.08 1506.7 percent of total billed charges "UNLISTED PROCEDURE, NERVOUS SYSTEM" 9515411_1 CDM 361 RC 64999 HCPCS outpatient 1586 1189.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1349.21 85.07 999999999 1237.08 1506.7 percent of total billed charges "UNLISTED PROCEDURE, NERVOUS SYSTEM" 9515411_1 CDM 361 RC 64999 HCPCS outpatient 1586 1189.5 MOLINA MCAID MOLINA MCAID 1322.72 83.4 999999999 1237.08 1506.7 percent of total billed charges "UNLISTED PROCEDURE, NERVOUS SYSTEM" 9515411_1 CDM 361 RC 64999 HCPCS outpatient 1586 1189.5 MOLINA MCR ADV MOLINA MCR ADV 1411.54 89 999999999 1237.08 1506.7 percent of total billed charges "UNLISTED PROCEDURE, NERVOUS SYSTEM" 9515411_1 CDM 361 RC 64999 HCPCS outpatient 1586 1189.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1411.54 89 999999999 1237.08 1506.7 percent of total billed charges "UNLISTED PROCEDURE, NERVOUS SYSTEM" 9515411_1 CDM 361 RC 64999 HCPCS outpatient 1586 1189.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1411.54 89 999999999 1237.08 1506.7 percent of total billed charges "UNLISTED PROCEDURE, NERVOUS SYSTEM" 9515411_1 CDM 361 RC 64999 HCPCS outpatient 1586 1189.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1427.4 90 999999999 1237.08 1506.7 percent of total billed charges "UNLISTED PROCEDURE, NERVOUS SYSTEM" 9515411_1 CDM 361 RC 64999 HCPCS outpatient 1586 1189.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1506.7 95 999999999 1237.08 1506.7 percent of total billed charges "UNLISTED PROCEDURE, NERVOUS SYSTEM" 9515411_1 CDM 361 RC 64999 HCPCS outpatient 1586 1189.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1506.7 95 999999999 1237.08 1506.7 percent of total billed charges "UNLISTED PROCEDURE, NERVOUS SYSTEM" 9515411_1 CDM 361 RC 64999 HCPCS outpatient 1586 1189.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1411.54 89 999999999 1237.08 1506.7 percent of total billed charges "UNLISTED PROCEDURE, NERVOUS SYSTEM" 9515411_1 CDM 361 RC 64999 HCPCS outpatient 1586 1189.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1395.68 88 999999999 1237.08 1506.7 percent of total billed charges "UNLISTED PROCEDURE, NERVOUS SYSTEM" 9515411_1 CDM 361 RC 64999 HCPCS outpatient 1586 1189.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1411.54 89 999999999 1237.08 1506.7 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 9515414_1 CDM 761 RC 16020 HCPCS outpatient 347 260.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 312.3 999999999 270.66 329.65 case rate "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 9515414_1 CDM 761 RC 16020 HCPCS outpatient 347 260.25 AETNA MCR ADV AETNA MCR ADV 270.66 78 999999999 270.66 329.65 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 9515414_1 CDM 761 RC 16020 HCPCS outpatient 347 260.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 303.87 87.57 999999999 270.66 329.65 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 9515414_1 CDM 761 RC 16020 HCPCS outpatient 347 260.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 295.19 85.07 999999999 270.66 329.65 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 9515414_1 CDM 761 RC 16020 HCPCS outpatient 347 260.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 295.19 85.07 999999999 270.66 329.65 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 9515414_1 CDM 761 RC 16020 HCPCS outpatient 347 260.25 MOLINA MCAID MOLINA MCAID 289.4 83.4 999999999 270.66 329.65 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 9515414_1 CDM 761 RC 16020 HCPCS outpatient 347 260.25 MOLINA MCR ADV MOLINA MCR ADV 308.83 89 999999999 270.66 329.65 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 9515414_1 CDM 761 RC 16020 HCPCS outpatient 347 260.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 308.83 89 999999999 270.66 329.65 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 9515414_1 CDM 761 RC 16020 HCPCS outpatient 347 260.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 308.83 89 999999999 270.66 329.65 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 9515414_1 CDM 761 RC 16020 HCPCS outpatient 347 260.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 312.3 90 999999999 270.66 329.65 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 9515414_1 CDM 761 RC 16020 HCPCS outpatient 347 260.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 329.65 95 999999999 270.66 329.65 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 9515414_1 CDM 761 RC 16020 HCPCS outpatient 347 260.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 329.65 95 999999999 270.66 329.65 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 9515414_1 CDM 761 RC 16020 HCPCS outpatient 347 260.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 308.83 89 999999999 270.66 329.65 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 9515414_1 CDM 761 RC 16020 HCPCS outpatient 347 260.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 305.36 88 999999999 270.66 329.65 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 9515414_1 CDM 761 RC 16020 HCPCS outpatient 347 260.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 308.83 89 999999999 270.66 329.65 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 9515414_2 CDM 761 RC 16020 HCPCS outpatient 418 313.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 376.2 999999999 326.04 397.1 case rate "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 9515414_2 CDM 761 RC 16020 HCPCS outpatient 418 313.5 AETNA MCR ADV AETNA MCR ADV 326.04 78 999999999 326.04 397.1 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 9515414_2 CDM 761 RC 16020 HCPCS outpatient 418 313.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 366.04 87.57 999999999 326.04 397.1 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 9515414_2 CDM 761 RC 16020 HCPCS outpatient 418 313.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 355.59 85.07 999999999 326.04 397.1 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 9515414_2 CDM 761 RC 16020 HCPCS outpatient 418 313.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 355.59 85.07 999999999 326.04 397.1 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 9515414_2 CDM 761 RC 16020 HCPCS outpatient 418 313.5 MOLINA MCAID MOLINA MCAID 348.61 83.4 999999999 326.04 397.1 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 9515414_2 CDM 761 RC 16020 HCPCS outpatient 418 313.5 MOLINA MCR ADV MOLINA MCR ADV 372.02 89 999999999 326.04 397.1 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 9515414_2 CDM 761 RC 16020 HCPCS outpatient 418 313.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 372.02 89 999999999 326.04 397.1 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 9515414_2 CDM 761 RC 16020 HCPCS outpatient 418 313.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 372.02 89 999999999 326.04 397.1 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 9515414_2 CDM 761 RC 16020 HCPCS outpatient 418 313.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 376.2 90 999999999 326.04 397.1 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 9515414_2 CDM 761 RC 16020 HCPCS outpatient 418 313.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 397.1 95 999999999 326.04 397.1 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 9515414_2 CDM 761 RC 16020 HCPCS outpatient 418 313.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 397.1 95 999999999 326.04 397.1 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 9515414_2 CDM 761 RC 16020 HCPCS outpatient 418 313.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 372.02 89 999999999 326.04 397.1 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 9515414_2 CDM 761 RC 16020 HCPCS outpatient 418 313.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 367.84 88 999999999 326.04 397.1 percent of total billed charges "DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)" 9515414_2 CDM 761 RC 16020 HCPCS outpatient 418 313.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 372.02 89 999999999 326.04 397.1 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 9515417_1 CDM 761 RC 11042 HCPCS outpatient 180 135 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 162 999999999 140.4 171 case rate "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 9515417_1 CDM 761 RC 11042 HCPCS outpatient 180 135 AETNA MCR ADV AETNA MCR ADV 140.4 78 999999999 140.4 171 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 9515417_1 CDM 761 RC 11042 HCPCS outpatient 180 135 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 157.63 87.57 999999999 140.4 171 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 9515417_1 CDM 761 RC 11042 HCPCS outpatient 180 135 COORDINATED CARE MCAID COORDINATED CARE MCAID 153.13 85.07 999999999 140.4 171 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 9515417_1 CDM 761 RC 11042 HCPCS outpatient 180 135 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 153.13 85.07 999999999 140.4 171 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 9515417_1 CDM 761 RC 11042 HCPCS outpatient 180 135 MOLINA MCAID MOLINA MCAID 150.12 83.4 999999999 140.4 171 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 9515417_1 CDM 761 RC 11042 HCPCS outpatient 180 135 MOLINA MCR ADV MOLINA MCR ADV 160.2 89 999999999 140.4 171 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 9515417_1 CDM 761 RC 11042 HCPCS outpatient 180 135 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 160.2 89 999999999 140.4 171 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 9515417_1 CDM 761 RC 11042 HCPCS outpatient 180 135 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 160.2 89 999999999 140.4 171 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 9515417_1 CDM 761 RC 11042 HCPCS outpatient 180 135 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 162 90 999999999 140.4 171 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 9515417_1 CDM 761 RC 11042 HCPCS outpatient 180 135 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 171 95 999999999 140.4 171 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 9515417_1 CDM 761 RC 11042 HCPCS outpatient 180 135 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 171 95 999999999 140.4 171 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 9515417_1 CDM 761 RC 11042 HCPCS outpatient 180 135 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 160.2 89 999999999 140.4 171 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 9515417_1 CDM 761 RC 11042 HCPCS outpatient 180 135 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 158.4 88 999999999 140.4 171 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 9515417_1 CDM 761 RC 11042 HCPCS outpatient 180 135 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 160.2 89 999999999 140.4 171 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 9515417_2 CDM 761 RC 11042 HCPCS outpatient 814 610.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 732.6 999999999 634.92 773.3 case rate "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 9515417_2 CDM 761 RC 11042 HCPCS outpatient 814 610.5 AETNA MCR ADV AETNA MCR ADV 634.92 78 999999999 634.92 773.3 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 9515417_2 CDM 761 RC 11042 HCPCS outpatient 814 610.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 712.82 87.57 999999999 634.92 773.3 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 9515417_2 CDM 761 RC 11042 HCPCS outpatient 814 610.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 692.47 85.07 999999999 634.92 773.3 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 9515417_2 CDM 761 RC 11042 HCPCS outpatient 814 610.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 692.47 85.07 999999999 634.92 773.3 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 9515417_2 CDM 761 RC 11042 HCPCS outpatient 814 610.5 MOLINA MCAID MOLINA MCAID 678.88 83.4 999999999 634.92 773.3 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 9515417_2 CDM 761 RC 11042 HCPCS outpatient 814 610.5 MOLINA MCR ADV MOLINA MCR ADV 724.46 89 999999999 634.92 773.3 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 9515417_2 CDM 761 RC 11042 HCPCS outpatient 814 610.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 724.46 89 999999999 634.92 773.3 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 9515417_2 CDM 761 RC 11042 HCPCS outpatient 814 610.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 724.46 89 999999999 634.92 773.3 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 9515417_2 CDM 761 RC 11042 HCPCS outpatient 814 610.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 732.6 90 999999999 634.92 773.3 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 9515417_2 CDM 761 RC 11042 HCPCS outpatient 814 610.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 773.3 95 999999999 634.92 773.3 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 9515417_2 CDM 761 RC 11042 HCPCS outpatient 814 610.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 773.3 95 999999999 634.92 773.3 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 9515417_2 CDM 761 RC 11042 HCPCS outpatient 814 610.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 724.46 89 999999999 634.92 773.3 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 9515417_2 CDM 761 RC 11042 HCPCS outpatient 814 610.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 716.32 88 999999999 634.92 773.3 percent of total billed charges "DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS" 9515417_2 CDM 761 RC 11042 HCPCS outpatient 814 610.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 724.46 89 999999999 634.92 773.3 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 9515423_1 CDM 361 RC 10061 HCPCS outpatient 420 315 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 378 999999999 327.6 399 case rate "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 9515423_1 CDM 361 RC 10061 HCPCS outpatient 420 315 AETNA MCR ADV AETNA MCR ADV 327.6 78 999999999 327.6 399 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 9515423_1 CDM 361 RC 10061 HCPCS outpatient 420 315 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 367.79 87.57 999999999 327.6 399 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 9515423_1 CDM 361 RC 10061 HCPCS outpatient 420 315 COORDINATED CARE MCAID COORDINATED CARE MCAID 357.29 85.07 999999999 327.6 399 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 9515423_1 CDM 361 RC 10061 HCPCS outpatient 420 315 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 357.29 85.07 999999999 327.6 399 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 9515423_1 CDM 361 RC 10061 HCPCS outpatient 420 315 MOLINA MCAID MOLINA MCAID 350.28 83.4 999999999 327.6 399 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 9515423_1 CDM 361 RC 10061 HCPCS outpatient 420 315 MOLINA MCR ADV MOLINA MCR ADV 373.8 89 999999999 327.6 399 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 9515423_1 CDM 361 RC 10061 HCPCS outpatient 420 315 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 373.8 89 999999999 327.6 399 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 9515423_1 CDM 361 RC 10061 HCPCS outpatient 420 315 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 373.8 89 999999999 327.6 399 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 9515423_1 CDM 361 RC 10061 HCPCS outpatient 420 315 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 378 90 999999999 327.6 399 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 9515423_1 CDM 361 RC 10061 HCPCS outpatient 420 315 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 399 95 999999999 327.6 399 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 9515423_1 CDM 361 RC 10061 HCPCS outpatient 420 315 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 399 95 999999999 327.6 399 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 9515423_1 CDM 361 RC 10061 HCPCS outpatient 420 315 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 373.8 89 999999999 327.6 399 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 9515423_1 CDM 361 RC 10061 HCPCS outpatient 420 315 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 369.6 88 999999999 327.6 399 percent of total billed charges "INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE" 9515423_1 CDM 361 RC 10061 HCPCS outpatient 420 315 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 373.8 89 999999999 327.6 399 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 9515435_1 CDM 361 RC 11730 HCPCS outpatient 205 153.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 184.5 999999999 159.9 194.75 case rate "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 9515435_1 CDM 361 RC 11730 HCPCS outpatient 205 153.75 AETNA MCR ADV AETNA MCR ADV 159.9 78 999999999 159.9 194.75 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 9515435_1 CDM 361 RC 11730 HCPCS outpatient 205 153.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 179.52 87.57 999999999 159.9 194.75 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 9515435_1 CDM 361 RC 11730 HCPCS outpatient 205 153.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 174.39 85.07 999999999 159.9 194.75 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 9515435_1 CDM 361 RC 11730 HCPCS outpatient 205 153.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 174.39 85.07 999999999 159.9 194.75 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 9515435_1 CDM 361 RC 11730 HCPCS outpatient 205 153.75 MOLINA MCAID MOLINA MCAID 170.97 83.4 999999999 159.9 194.75 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 9515435_1 CDM 361 RC 11730 HCPCS outpatient 205 153.75 MOLINA MCR ADV MOLINA MCR ADV 182.45 89 999999999 159.9 194.75 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 9515435_1 CDM 361 RC 11730 HCPCS outpatient 205 153.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 182.45 89 999999999 159.9 194.75 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 9515435_1 CDM 361 RC 11730 HCPCS outpatient 205 153.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 182.45 89 999999999 159.9 194.75 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 9515435_1 CDM 361 RC 11730 HCPCS outpatient 205 153.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 184.5 90 999999999 159.9 194.75 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 9515435_1 CDM 361 RC 11730 HCPCS outpatient 205 153.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 194.75 95 999999999 159.9 194.75 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 9515435_1 CDM 361 RC 11730 HCPCS outpatient 205 153.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 194.75 95 999999999 159.9 194.75 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 9515435_1 CDM 361 RC 11730 HCPCS outpatient 205 153.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 182.45 89 999999999 159.9 194.75 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 9515435_1 CDM 361 RC 11730 HCPCS outpatient 205 153.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 180.4 88 999999999 159.9 194.75 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 9515435_1 CDM 361 RC 11730 HCPCS outpatient 205 153.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 182.45 89 999999999 159.9 194.75 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 9515435_2 CDM 361 RC 11730 HCPCS outpatient 205 153.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 184.5 999999999 159.9 194.75 case rate "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 9515435_2 CDM 361 RC 11730 HCPCS outpatient 205 153.75 AETNA MCR ADV AETNA MCR ADV 159.9 78 999999999 159.9 194.75 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 9515435_2 CDM 361 RC 11730 HCPCS outpatient 205 153.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 179.52 87.57 999999999 159.9 194.75 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 9515435_2 CDM 361 RC 11730 HCPCS outpatient 205 153.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 174.39 85.07 999999999 159.9 194.75 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 9515435_2 CDM 361 RC 11730 HCPCS outpatient 205 153.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 174.39 85.07 999999999 159.9 194.75 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 9515435_2 CDM 361 RC 11730 HCPCS outpatient 205 153.75 MOLINA MCAID MOLINA MCAID 170.97 83.4 999999999 159.9 194.75 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 9515435_2 CDM 361 RC 11730 HCPCS outpatient 205 153.75 MOLINA MCR ADV MOLINA MCR ADV 182.45 89 999999999 159.9 194.75 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 9515435_2 CDM 361 RC 11730 HCPCS outpatient 205 153.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 182.45 89 999999999 159.9 194.75 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 9515435_2 CDM 361 RC 11730 HCPCS outpatient 205 153.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 182.45 89 999999999 159.9 194.75 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 9515435_2 CDM 361 RC 11730 HCPCS outpatient 205 153.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 184.5 90 999999999 159.9 194.75 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 9515435_2 CDM 361 RC 11730 HCPCS outpatient 205 153.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 194.75 95 999999999 159.9 194.75 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 9515435_2 CDM 361 RC 11730 HCPCS outpatient 205 153.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 194.75 95 999999999 159.9 194.75 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 9515435_2 CDM 361 RC 11730 HCPCS outpatient 205 153.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 182.45 89 999999999 159.9 194.75 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 9515435_2 CDM 361 RC 11730 HCPCS outpatient 205 153.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 180.4 88 999999999 159.9 194.75 percent of total billed charges "AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE" 9515435_2 CDM 361 RC 11730 HCPCS outpatient 205 153.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 182.45 89 999999999 159.9 194.75 percent of total billed charges "APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA" 9515438_1 CDM 361 RC 15271 HCPCS outpatient 1900 1425 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1710 999999999 1482 1805 case rate "APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA" 9515438_1 CDM 361 RC 15271 HCPCS outpatient 1900 1425 AETNA MCR ADV AETNA MCR ADV 1482 78 999999999 1482 1805 percent of total billed charges "APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA" 9515438_1 CDM 361 RC 15271 HCPCS outpatient 1900 1425 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1663.83 87.57 999999999 1482 1805 percent of total billed charges "APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA" 9515438_1 CDM 361 RC 15271 HCPCS outpatient 1900 1425 COORDINATED CARE MCAID COORDINATED CARE MCAID 1616.33 85.07 999999999 1482 1805 percent of total billed charges "APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA" 9515438_1 CDM 361 RC 15271 HCPCS outpatient 1900 1425 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1616.33 85.07 999999999 1482 1805 percent of total billed charges "APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA" 9515438_1 CDM 361 RC 15271 HCPCS outpatient 1900 1425 MOLINA MCAID MOLINA MCAID 1584.6 83.4 999999999 1482 1805 percent of total billed charges "APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA" 9515438_1 CDM 361 RC 15271 HCPCS outpatient 1900 1425 MOLINA MCR ADV MOLINA MCR ADV 1691 89 999999999 1482 1805 percent of total billed charges "APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA" 9515438_1 CDM 361 RC 15271 HCPCS outpatient 1900 1425 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1691 89 999999999 1482 1805 percent of total billed charges "APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA" 9515438_1 CDM 361 RC 15271 HCPCS outpatient 1900 1425 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1691 89 999999999 1482 1805 percent of total billed charges "APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA" 9515438_1 CDM 361 RC 15271 HCPCS outpatient 1900 1425 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1710 90 999999999 1482 1805 percent of total billed charges "APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA" 9515438_1 CDM 361 RC 15271 HCPCS outpatient 1900 1425 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1805 95 999999999 1482 1805 percent of total billed charges "APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA" 9515438_1 CDM 361 RC 15271 HCPCS outpatient 1900 1425 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1805 95 999999999 1482 1805 percent of total billed charges "APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA" 9515438_1 CDM 361 RC 15271 HCPCS outpatient 1900 1425 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1691 89 999999999 1482 1805 percent of total billed charges "APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA" 9515438_1 CDM 361 RC 15271 HCPCS outpatient 1900 1425 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1672 88 999999999 1482 1805 percent of total billed charges "APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA" 9515438_1 CDM 361 RC 15271 HCPCS outpatient 1900 1425 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1691 89 999999999 1482 1805 percent of total billed charges "APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA" 9515439_1 CDM 361 RC 15275 HCPCS outpatient 1900 1425 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1710 999999999 1482 1805 case rate "APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA" 9515439_1 CDM 361 RC 15275 HCPCS outpatient 1900 1425 AETNA MCR ADV AETNA MCR ADV 1482 78 999999999 1482 1805 percent of total billed charges "APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA" 9515439_1 CDM 361 RC 15275 HCPCS outpatient 1900 1425 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1663.83 87.57 999999999 1482 1805 percent of total billed charges "APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA" 9515439_1 CDM 361 RC 15275 HCPCS outpatient 1900 1425 COORDINATED CARE MCAID COORDINATED CARE MCAID 1616.33 85.07 999999999 1482 1805 percent of total billed charges "APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA" 9515439_1 CDM 361 RC 15275 HCPCS outpatient 1900 1425 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1616.33 85.07 999999999 1482 1805 percent of total billed charges "APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA" 9515439_1 CDM 361 RC 15275 HCPCS outpatient 1900 1425 MOLINA MCAID MOLINA MCAID 1584.6 83.4 999999999 1482 1805 percent of total billed charges "APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA" 9515439_1 CDM 361 RC 15275 HCPCS outpatient 1900 1425 MOLINA MCR ADV MOLINA MCR ADV 1691 89 999999999 1482 1805 percent of total billed charges "APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA" 9515439_1 CDM 361 RC 15275 HCPCS outpatient 1900 1425 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1691 89 999999999 1482 1805 percent of total billed charges "APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA" 9515439_1 CDM 361 RC 15275 HCPCS outpatient 1900 1425 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1691 89 999999999 1482 1805 percent of total billed charges "APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA" 9515439_1 CDM 361 RC 15275 HCPCS outpatient 1900 1425 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1710 90 999999999 1482 1805 percent of total billed charges "APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA" 9515439_1 CDM 361 RC 15275 HCPCS outpatient 1900 1425 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1805 95 999999999 1482 1805 percent of total billed charges "APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA" 9515439_1 CDM 361 RC 15275 HCPCS outpatient 1900 1425 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1805 95 999999999 1482 1805 percent of total billed charges "APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA" 9515439_1 CDM 361 RC 15275 HCPCS outpatient 1900 1425 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1691 89 999999999 1482 1805 percent of total billed charges "APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA" 9515439_1 CDM 361 RC 15275 HCPCS outpatient 1900 1425 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1672 88 999999999 1482 1805 percent of total billed charges "APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA" 9515439_1 CDM 361 RC 15275 HCPCS outpatient 1900 1425 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1691 89 999999999 1482 1805 percent of total billed charges "INJECTION, ANESTHETIC AGENT; SPHENOPALATINE GANGLION" 9515450_1 CDM 361 RC 64505 HCPCS outpatient 1050 787.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 945 999999999 819 997.5 case rate "INJECTION, ANESTHETIC AGENT; SPHENOPALATINE GANGLION" 9515450_1 CDM 361 RC 64505 HCPCS outpatient 1050 787.5 AETNA MCR ADV AETNA MCR ADV 819 78 999999999 819 997.5 percent of total billed charges "INJECTION, ANESTHETIC AGENT; SPHENOPALATINE GANGLION" 9515450_1 CDM 361 RC 64505 HCPCS outpatient 1050 787.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 919.49 87.57 999999999 819 997.5 percent of total billed charges "INJECTION, ANESTHETIC AGENT; SPHENOPALATINE GANGLION" 9515450_1 CDM 361 RC 64505 HCPCS outpatient 1050 787.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 893.24 85.07 999999999 819 997.5 percent of total billed charges "INJECTION, ANESTHETIC AGENT; SPHENOPALATINE GANGLION" 9515450_1 CDM 361 RC 64505 HCPCS outpatient 1050 787.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 893.24 85.07 999999999 819 997.5 percent of total billed charges "INJECTION, ANESTHETIC AGENT; SPHENOPALATINE GANGLION" 9515450_1 CDM 361 RC 64505 HCPCS outpatient 1050 787.5 MOLINA MCAID MOLINA MCAID 875.7 83.4 999999999 819 997.5 percent of total billed charges "INJECTION, ANESTHETIC AGENT; SPHENOPALATINE GANGLION" 9515450_1 CDM 361 RC 64505 HCPCS outpatient 1050 787.5 MOLINA MCR ADV MOLINA MCR ADV 934.5 89 999999999 819 997.5 percent of total billed charges "INJECTION, ANESTHETIC AGENT; SPHENOPALATINE GANGLION" 9515450_1 CDM 361 RC 64505 HCPCS outpatient 1050 787.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 934.5 89 999999999 819 997.5 percent of total billed charges "INJECTION, ANESTHETIC AGENT; SPHENOPALATINE GANGLION" 9515450_1 CDM 361 RC 64505 HCPCS outpatient 1050 787.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 934.5 89 999999999 819 997.5 percent of total billed charges "INJECTION, ANESTHETIC AGENT; SPHENOPALATINE GANGLION" 9515450_1 CDM 361 RC 64505 HCPCS outpatient 1050 787.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 945 90 999999999 819 997.5 percent of total billed charges "INJECTION, ANESTHETIC AGENT; SPHENOPALATINE GANGLION" 9515450_1 CDM 361 RC 64505 HCPCS outpatient 1050 787.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 997.5 95 999999999 819 997.5 percent of total billed charges "INJECTION, ANESTHETIC AGENT; SPHENOPALATINE GANGLION" 9515450_1 CDM 361 RC 64505 HCPCS outpatient 1050 787.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 997.5 95 999999999 819 997.5 percent of total billed charges "INJECTION, ANESTHETIC AGENT; SPHENOPALATINE GANGLION" 9515450_1 CDM 361 RC 64505 HCPCS outpatient 1050 787.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 934.5 89 999999999 819 997.5 percent of total billed charges "INJECTION, ANESTHETIC AGENT; SPHENOPALATINE GANGLION" 9515450_1 CDM 361 RC 64505 HCPCS outpatient 1050 787.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 924 88 999999999 819 997.5 percent of total billed charges "INJECTION, ANESTHETIC AGENT; SPHENOPALATINE GANGLION" 9515450_1 CDM 361 RC 64505 HCPCS outpatient 1050 787.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 934.5 89 999999999 819 997.5 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 9515530_1 CDM 361 RC 20606 HCPCS outpatient 1115 836.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1003.5 999999999 869.7 1059.25 case rate "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 9515530_1 CDM 361 RC 20606 HCPCS outpatient 1115 836.25 AETNA MCR ADV AETNA MCR ADV 869.7 78 999999999 869.7 1059.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 9515530_1 CDM 361 RC 20606 HCPCS outpatient 1115 836.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 976.41 87.57 999999999 869.7 1059.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 9515530_1 CDM 361 RC 20606 HCPCS outpatient 1115 836.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 948.53 85.07 999999999 869.7 1059.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 9515530_1 CDM 361 RC 20606 HCPCS outpatient 1115 836.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 948.53 85.07 999999999 869.7 1059.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 9515530_1 CDM 361 RC 20606 HCPCS outpatient 1115 836.25 MOLINA MCAID MOLINA MCAID 929.91 83.4 999999999 869.7 1059.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 9515530_1 CDM 361 RC 20606 HCPCS outpatient 1115 836.25 MOLINA MCR ADV MOLINA MCR ADV 992.35 89 999999999 869.7 1059.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 9515530_1 CDM 361 RC 20606 HCPCS outpatient 1115 836.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 992.35 89 999999999 869.7 1059.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 9515530_1 CDM 361 RC 20606 HCPCS outpatient 1115 836.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 992.35 89 999999999 869.7 1059.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 9515530_1 CDM 361 RC 20606 HCPCS outpatient 1115 836.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1003.5 90 999999999 869.7 1059.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 9515530_1 CDM 361 RC 20606 HCPCS outpatient 1115 836.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1059.25 95 999999999 869.7 1059.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 9515530_1 CDM 361 RC 20606 HCPCS outpatient 1115 836.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1059.25 95 999999999 869.7 1059.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 9515530_1 CDM 361 RC 20606 HCPCS outpatient 1115 836.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 992.35 89 999999999 869.7 1059.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 9515530_1 CDM 361 RC 20606 HCPCS outpatient 1115 836.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 981.2 88 999999999 869.7 1059.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 9515530_1 CDM 361 RC 20606 HCPCS outpatient 1115 836.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 992.35 89 999999999 869.7 1059.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 9515531_1 CDM 361 RC 20611 HCPCS outpatient 875 656.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 787.5 999999999 682.5 831.25 case rate "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 9515531_1 CDM 361 RC 20611 HCPCS outpatient 875 656.25 AETNA MCR ADV AETNA MCR ADV 682.5 78 999999999 682.5 831.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 9515531_1 CDM 361 RC 20611 HCPCS outpatient 875 656.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 766.24 87.57 999999999 682.5 831.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 9515531_1 CDM 361 RC 20611 HCPCS outpatient 875 656.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 744.36 85.07 999999999 682.5 831.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 9515531_1 CDM 361 RC 20611 HCPCS outpatient 875 656.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 744.36 85.07 999999999 682.5 831.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 9515531_1 CDM 361 RC 20611 HCPCS outpatient 875 656.25 MOLINA MCAID MOLINA MCAID 729.75 83.4 999999999 682.5 831.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 9515531_1 CDM 361 RC 20611 HCPCS outpatient 875 656.25 MOLINA MCR ADV MOLINA MCR ADV 778.75 89 999999999 682.5 831.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 9515531_1 CDM 361 RC 20611 HCPCS outpatient 875 656.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 778.75 89 999999999 682.5 831.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 9515531_1 CDM 361 RC 20611 HCPCS outpatient 875 656.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 778.75 89 999999999 682.5 831.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 9515531_1 CDM 361 RC 20611 HCPCS outpatient 875 656.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 787.5 90 999999999 682.5 831.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 9515531_1 CDM 361 RC 20611 HCPCS outpatient 875 656.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 831.25 95 999999999 682.5 831.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 9515531_1 CDM 361 RC 20611 HCPCS outpatient 875 656.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 831.25 95 999999999 682.5 831.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 9515531_1 CDM 361 RC 20611 HCPCS outpatient 875 656.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 778.75 89 999999999 682.5 831.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 9515531_1 CDM 361 RC 20611 HCPCS outpatient 875 656.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 770 88 999999999 682.5 831.25 percent of total billed charges "ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING" 9515531_1 CDM 361 RC 20611 HCPCS outpatient 875 656.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 778.75 89 999999999 682.5 831.25 percent of total billed charges CHANGE OF CYSTOSTOMY TUBE; SIMPLE 9515555_1 CDM 361 RC 51705 HCPCS outpatient 154 115.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 138.6 999999999 120.12 146.3 case rate CHANGE OF CYSTOSTOMY TUBE; SIMPLE 9515555_1 CDM 361 RC 51705 HCPCS outpatient 154 115.5 AETNA MCR ADV AETNA MCR ADV 120.12 78 999999999 120.12 146.3 percent of total billed charges CHANGE OF CYSTOSTOMY TUBE; SIMPLE 9515555_1 CDM 361 RC 51705 HCPCS outpatient 154 115.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 134.86 87.57 999999999 120.12 146.3 percent of total billed charges CHANGE OF CYSTOSTOMY TUBE; SIMPLE 9515555_1 CDM 361 RC 51705 HCPCS outpatient 154 115.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 131.01 85.07 999999999 120.12 146.3 percent of total billed charges CHANGE OF CYSTOSTOMY TUBE; SIMPLE 9515555_1 CDM 361 RC 51705 HCPCS outpatient 154 115.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 131.01 85.07 999999999 120.12 146.3 percent of total billed charges CHANGE OF CYSTOSTOMY TUBE; SIMPLE 9515555_1 CDM 361 RC 51705 HCPCS outpatient 154 115.5 MOLINA MCAID MOLINA MCAID 128.44 83.4 999999999 120.12 146.3 percent of total billed charges CHANGE OF CYSTOSTOMY TUBE; SIMPLE 9515555_1 CDM 361 RC 51705 HCPCS outpatient 154 115.5 MOLINA MCR ADV MOLINA MCR ADV 137.06 89 999999999 120.12 146.3 percent of total billed charges CHANGE OF CYSTOSTOMY TUBE; SIMPLE 9515555_1 CDM 361 RC 51705 HCPCS outpatient 154 115.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 137.06 89 999999999 120.12 146.3 percent of total billed charges CHANGE OF CYSTOSTOMY TUBE; SIMPLE 9515555_1 CDM 361 RC 51705 HCPCS outpatient 154 115.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 137.06 89 999999999 120.12 146.3 percent of total billed charges CHANGE OF CYSTOSTOMY TUBE; SIMPLE 9515555_1 CDM 361 RC 51705 HCPCS outpatient 154 115.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 138.6 90 999999999 120.12 146.3 percent of total billed charges CHANGE OF CYSTOSTOMY TUBE; SIMPLE 9515555_1 CDM 361 RC 51705 HCPCS outpatient 154 115.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 146.3 95 999999999 120.12 146.3 percent of total billed charges CHANGE OF CYSTOSTOMY TUBE; SIMPLE 9515555_1 CDM 361 RC 51705 HCPCS outpatient 154 115.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 146.3 95 999999999 120.12 146.3 percent of total billed charges CHANGE OF CYSTOSTOMY TUBE; SIMPLE 9515555_1 CDM 361 RC 51705 HCPCS outpatient 154 115.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 137.06 89 999999999 120.12 146.3 percent of total billed charges CHANGE OF CYSTOSTOMY TUBE; SIMPLE 9515555_1 CDM 361 RC 51705 HCPCS outpatient 154 115.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 135.52 88 999999999 120.12 146.3 percent of total billed charges CHANGE OF CYSTOSTOMY TUBE; SIMPLE 9515555_1 CDM 361 RC 51705 HCPCS outpatient 154 115.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 137.06 89 999999999 120.12 146.3 percent of total billed charges CHANGE OF CYSTOSTOMY TUBE; SIMPLE 9515555_2 CDM 361 RC 51705 HCPCS outpatient 1168 876 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1051.2 999999999 911.04 1109.6 case rate CHANGE OF CYSTOSTOMY TUBE; SIMPLE 9515555_2 CDM 361 RC 51705 HCPCS outpatient 1168 876 AETNA MCR ADV AETNA MCR ADV 911.04 78 999999999 911.04 1109.6 percent of total billed charges CHANGE OF CYSTOSTOMY TUBE; SIMPLE 9515555_2 CDM 361 RC 51705 HCPCS outpatient 1168 876 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1022.82 87.57 999999999 911.04 1109.6 percent of total billed charges CHANGE OF CYSTOSTOMY TUBE; SIMPLE 9515555_2 CDM 361 RC 51705 HCPCS outpatient 1168 876 COORDINATED CARE MCAID COORDINATED CARE MCAID 993.62 85.07 999999999 911.04 1109.6 percent of total billed charges CHANGE OF CYSTOSTOMY TUBE; SIMPLE 9515555_2 CDM 361 RC 51705 HCPCS outpatient 1168 876 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 993.62 85.07 999999999 911.04 1109.6 percent of total billed charges CHANGE OF CYSTOSTOMY TUBE; SIMPLE 9515555_2 CDM 361 RC 51705 HCPCS outpatient 1168 876 MOLINA MCAID MOLINA MCAID 974.11 83.4 999999999 911.04 1109.6 percent of total billed charges CHANGE OF CYSTOSTOMY TUBE; SIMPLE 9515555_2 CDM 361 RC 51705 HCPCS outpatient 1168 876 MOLINA MCR ADV MOLINA MCR ADV 1039.52 89 999999999 911.04 1109.6 percent of total billed charges CHANGE OF CYSTOSTOMY TUBE; SIMPLE 9515555_2 CDM 361 RC 51705 HCPCS outpatient 1168 876 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1039.52 89 999999999 911.04 1109.6 percent of total billed charges CHANGE OF CYSTOSTOMY TUBE; SIMPLE 9515555_2 CDM 361 RC 51705 HCPCS outpatient 1168 876 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1039.52 89 999999999 911.04 1109.6 percent of total billed charges CHANGE OF CYSTOSTOMY TUBE; SIMPLE 9515555_2 CDM 361 RC 51705 HCPCS outpatient 1168 876 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1051.2 90 999999999 911.04 1109.6 percent of total billed charges CHANGE OF CYSTOSTOMY TUBE; SIMPLE 9515555_2 CDM 361 RC 51705 HCPCS outpatient 1168 876 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1109.6 95 999999999 911.04 1109.6 percent of total billed charges CHANGE OF CYSTOSTOMY TUBE; SIMPLE 9515555_2 CDM 361 RC 51705 HCPCS outpatient 1168 876 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1109.6 95 999999999 911.04 1109.6 percent of total billed charges CHANGE OF CYSTOSTOMY TUBE; SIMPLE 9515555_2 CDM 361 RC 51705 HCPCS outpatient 1168 876 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1039.52 89 999999999 911.04 1109.6 percent of total billed charges CHANGE OF CYSTOSTOMY TUBE; SIMPLE 9515555_2 CDM 361 RC 51705 HCPCS outpatient 1168 876 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1027.84 88 999999999 911.04 1109.6 percent of total billed charges CHANGE OF CYSTOSTOMY TUBE; SIMPLE 9515555_2 CDM 361 RC 51705 HCPCS outpatient 1168 876 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1039.52 89 999999999 911.04 1109.6 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); INITIAL, UP TO 1 HOUR" 9515578_1 CDM 260 RC 96365 HCPCS outpatient 502 376.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 451.8 90 999999999 391.56 476.9 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); INITIAL, UP TO 1 HOUR" 9515578_1 CDM 260 RC 96365 HCPCS outpatient 502 376.5 AETNA MCR ADV AETNA MCR ADV 391.56 78 999999999 391.56 476.9 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); INITIAL, UP TO 1 HOUR" 9515578_1 CDM 260 RC 96365 HCPCS outpatient 502 376.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 439.6 87.57 999999999 391.56 476.9 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); INITIAL, UP TO 1 HOUR" 9515578_1 CDM 260 RC 96365 HCPCS outpatient 502 376.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 427.05 85.07 999999999 391.56 476.9 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); INITIAL, UP TO 1 HOUR" 9515578_1 CDM 260 RC 96365 HCPCS outpatient 502 376.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 427.05 85.07 999999999 391.56 476.9 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); INITIAL, UP TO 1 HOUR" 9515578_1 CDM 260 RC 96365 HCPCS outpatient 502 376.5 MOLINA MCAID MOLINA MCAID 418.67 83.4 999999999 391.56 476.9 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); INITIAL, UP TO 1 HOUR" 9515578_1 CDM 260 RC 96365 HCPCS outpatient 502 376.5 MOLINA MCR ADV MOLINA MCR ADV 446.78 89 999999999 391.56 476.9 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); INITIAL, UP TO 1 HOUR" 9515578_1 CDM 260 RC 96365 HCPCS outpatient 502 376.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 446.78 89 999999999 391.56 476.9 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); INITIAL, UP TO 1 HOUR" 9515578_1 CDM 260 RC 96365 HCPCS outpatient 502 376.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 446.78 89 999999999 391.56 476.9 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); INITIAL, UP TO 1 HOUR" 9515578_1 CDM 260 RC 96365 HCPCS outpatient 502 376.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 451.8 90 999999999 391.56 476.9 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); INITIAL, UP TO 1 HOUR" 9515578_1 CDM 260 RC 96365 HCPCS outpatient 502 376.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 476.9 95 999999999 391.56 476.9 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); INITIAL, UP TO 1 HOUR" 9515578_1 CDM 260 RC 96365 HCPCS outpatient 502 376.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 476.9 95 999999999 391.56 476.9 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); INITIAL, UP TO 1 HOUR" 9515578_1 CDM 260 RC 96365 HCPCS outpatient 502 376.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 446.78 89 999999999 391.56 476.9 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); INITIAL, UP TO 1 HOUR" 9515578_1 CDM 260 RC 96365 HCPCS outpatient 502 376.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 441.76 88 999999999 391.56 476.9 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); INITIAL, UP TO 1 HOUR" 9515578_1 CDM 260 RC 96365 HCPCS outpatient 502 376.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 446.78 89 999999999 391.56 476.9 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); INITIAL, UP TO 1 HOUR" 9515578_2 CDM 260 RC 96365 HCPCS outpatient 502 376.5 MOLINA MCAID MOLINA MCAID 418.67 83.4 999999999 391.56 476.9 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); INITIAL, UP TO 1 HOUR" 9515578_2 CDM 260 RC 96365 HCPCS outpatient 502 376.5 MOLINA MCR ADV MOLINA MCR ADV 446.78 89 999999999 391.56 476.9 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); INITIAL, UP TO 1 HOUR" 9515578_2 CDM 260 RC 96365 HCPCS outpatient 502 376.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 446.78 89 999999999 391.56 476.9 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); INITIAL, UP TO 1 HOUR" 9515578_2 CDM 260 RC 96365 HCPCS outpatient 502 376.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 446.78 89 999999999 391.56 476.9 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); INITIAL, UP TO 1 HOUR" 9515578_2 CDM 260 RC 96365 HCPCS outpatient 502 376.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 451.8 90 999999999 391.56 476.9 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); INITIAL, UP TO 1 HOUR" 9515578_2 CDM 260 RC 96365 HCPCS outpatient 502 376.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 476.9 95 999999999 391.56 476.9 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); INITIAL, UP TO 1 HOUR" 9515578_2 CDM 260 RC 96365 HCPCS outpatient 502 376.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 476.9 95 999999999 391.56 476.9 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); INITIAL, UP TO 1 HOUR" 9515578_2 CDM 260 RC 96365 HCPCS outpatient 502 376.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 446.78 89 999999999 391.56 476.9 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); INITIAL, UP TO 1 HOUR" 9515578_2 CDM 260 RC 96365 HCPCS outpatient 502 376.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 441.76 88 999999999 391.56 476.9 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); INITIAL, UP TO 1 HOUR" 9515578_2 CDM 260 RC 96365 HCPCS outpatient 502 376.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 446.78 89 999999999 391.56 476.9 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); INITIAL, UP TO 1 HOUR" 9515578_2 CDM 260 RC 96365 HCPCS outpatient 502 376.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 451.8 90 999999999 391.56 476.9 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); INITIAL, UP TO 1 HOUR" 9515578_2 CDM 260 RC 96365 HCPCS outpatient 502 376.5 AETNA MCR ADV AETNA MCR ADV 391.56 78 999999999 391.56 476.9 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); INITIAL, UP TO 1 HOUR" 9515578_2 CDM 260 RC 96365 HCPCS outpatient 502 376.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 439.6 87.57 999999999 391.56 476.9 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); INITIAL, UP TO 1 HOUR" 9515578_2 CDM 260 RC 96365 HCPCS outpatient 502 376.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 427.05 85.07 999999999 391.56 476.9 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); INITIAL, UP TO 1 HOUR" 9515578_2 CDM 260 RC 96365 HCPCS outpatient 502 376.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 427.05 85.07 999999999 391.56 476.9 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515579_1 CDM 260 RC 96366 HCPCS outpatient 244 183 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 219.6 90 999999999 190.32 231.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515579_1 CDM 260 RC 96366 HCPCS outpatient 244 183 AETNA MCR ADV AETNA MCR ADV 190.32 78 999999999 190.32 231.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515579_1 CDM 260 RC 96366 HCPCS outpatient 244 183 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 213.67 87.57 999999999 190.32 231.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515579_1 CDM 260 RC 96366 HCPCS outpatient 244 183 COORDINATED CARE MCAID COORDINATED CARE MCAID 207.57 85.07 999999999 190.32 231.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515579_1 CDM 260 RC 96366 HCPCS outpatient 244 183 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 207.57 85.07 999999999 190.32 231.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515579_1 CDM 260 RC 96366 HCPCS outpatient 244 183 MOLINA MCAID MOLINA MCAID 203.5 83.4 999999999 190.32 231.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515579_1 CDM 260 RC 96366 HCPCS outpatient 244 183 MOLINA MCR ADV MOLINA MCR ADV 217.16 89 999999999 190.32 231.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515579_1 CDM 260 RC 96366 HCPCS outpatient 244 183 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 217.16 89 999999999 190.32 231.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515579_1 CDM 260 RC 96366 HCPCS outpatient 244 183 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 217.16 89 999999999 190.32 231.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515579_1 CDM 260 RC 96366 HCPCS outpatient 244 183 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 219.6 90 999999999 190.32 231.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515579_1 CDM 260 RC 96366 HCPCS outpatient 244 183 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 231.8 95 999999999 190.32 231.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515579_1 CDM 260 RC 96366 HCPCS outpatient 244 183 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 231.8 95 999999999 190.32 231.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515579_1 CDM 260 RC 96366 HCPCS outpatient 244 183 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 217.16 89 999999999 190.32 231.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515579_1 CDM 260 RC 96366 HCPCS outpatient 244 183 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 214.72 88 999999999 190.32 231.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515579_1 CDM 260 RC 96366 HCPCS outpatient 244 183 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 217.16 89 999999999 190.32 231.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515579_2 CDM 260 RC 96366 HCPCS outpatient 244 183 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 219.6 90 999999999 190.32 231.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515579_2 CDM 260 RC 96366 HCPCS outpatient 244 183 AETNA MCR ADV AETNA MCR ADV 190.32 78 999999999 190.32 231.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515579_2 CDM 260 RC 96366 HCPCS outpatient 244 183 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 213.67 87.57 999999999 190.32 231.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515579_2 CDM 260 RC 96366 HCPCS outpatient 244 183 COORDINATED CARE MCAID COORDINATED CARE MCAID 207.57 85.07 999999999 190.32 231.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515579_2 CDM 260 RC 96366 HCPCS outpatient 244 183 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 207.57 85.07 999999999 190.32 231.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515579_2 CDM 260 RC 96366 HCPCS outpatient 244 183 MOLINA MCAID MOLINA MCAID 203.5 83.4 999999999 190.32 231.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515579_2 CDM 260 RC 96366 HCPCS outpatient 244 183 MOLINA MCR ADV MOLINA MCR ADV 217.16 89 999999999 190.32 231.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515579_2 CDM 260 RC 96366 HCPCS outpatient 244 183 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 217.16 89 999999999 190.32 231.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515579_2 CDM 260 RC 96366 HCPCS outpatient 244 183 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 217.16 89 999999999 190.32 231.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515579_2 CDM 260 RC 96366 HCPCS outpatient 244 183 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 219.6 90 999999999 190.32 231.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515579_2 CDM 260 RC 96366 HCPCS outpatient 244 183 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 231.8 95 999999999 190.32 231.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515579_2 CDM 260 RC 96366 HCPCS outpatient 244 183 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 231.8 95 999999999 190.32 231.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515579_2 CDM 260 RC 96366 HCPCS outpatient 244 183 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 217.16 89 999999999 190.32 231.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515579_2 CDM 260 RC 96366 HCPCS outpatient 244 183 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 214.72 88 999999999 190.32 231.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515579_2 CDM 260 RC 96366 HCPCS outpatient 244 183 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 217.16 89 999999999 190.32 231.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG/SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515580_1 CDM 260 RC 96367 HCPCS outpatient 263 197.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 236.7 90 999999999 205.14 249.85 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG/SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515580_1 CDM 260 RC 96367 HCPCS outpatient 263 197.25 AETNA MCR ADV AETNA MCR ADV 205.14 78 999999999 205.14 249.85 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG/SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515580_1 CDM 260 RC 96367 HCPCS outpatient 263 197.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 230.31 87.57 999999999 205.14 249.85 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG/SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515580_1 CDM 260 RC 96367 HCPCS outpatient 263 197.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 223.73 85.07 999999999 205.14 249.85 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG/SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515580_1 CDM 260 RC 96367 HCPCS outpatient 263 197.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 223.73 85.07 999999999 205.14 249.85 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG/SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515580_1 CDM 260 RC 96367 HCPCS outpatient 263 197.25 MOLINA MCAID MOLINA MCAID 219.34 83.4 999999999 205.14 249.85 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG/SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515580_1 CDM 260 RC 96367 HCPCS outpatient 263 197.25 MOLINA MCR ADV MOLINA MCR ADV 234.07 89 999999999 205.14 249.85 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG/SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515580_1 CDM 260 RC 96367 HCPCS outpatient 263 197.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 234.07 89 999999999 205.14 249.85 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG/SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515580_1 CDM 260 RC 96367 HCPCS outpatient 263 197.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 234.07 89 999999999 205.14 249.85 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG/SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515580_1 CDM 260 RC 96367 HCPCS outpatient 263 197.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 236.7 90 999999999 205.14 249.85 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG/SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515580_1 CDM 260 RC 96367 HCPCS outpatient 263 197.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 249.85 95 999999999 205.14 249.85 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG/SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515580_1 CDM 260 RC 96367 HCPCS outpatient 263 197.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 249.85 95 999999999 205.14 249.85 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG/SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515580_1 CDM 260 RC 96367 HCPCS outpatient 263 197.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 234.07 89 999999999 205.14 249.85 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG/SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515580_1 CDM 260 RC 96367 HCPCS outpatient 263 197.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 231.44 88 999999999 205.14 249.85 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG/SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515580_1 CDM 260 RC 96367 HCPCS outpatient 263 197.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 234.07 89 999999999 205.14 249.85 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG/SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515580_2 CDM 260 RC 96367 HCPCS outpatient 263 197.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 236.7 90 999999999 205.14 249.85 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG/SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515580_2 CDM 260 RC 96367 HCPCS outpatient 263 197.25 AETNA MCR ADV AETNA MCR ADV 205.14 78 999999999 205.14 249.85 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG/SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515580_2 CDM 260 RC 96367 HCPCS outpatient 263 197.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 230.31 87.57 999999999 205.14 249.85 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG/SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515580_2 CDM 260 RC 96367 HCPCS outpatient 263 197.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 223.73 85.07 999999999 205.14 249.85 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG/SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515580_2 CDM 260 RC 96367 HCPCS outpatient 263 197.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 223.73 85.07 999999999 205.14 249.85 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG/SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515580_2 CDM 260 RC 96367 HCPCS outpatient 263 197.25 MOLINA MCAID MOLINA MCAID 219.34 83.4 999999999 205.14 249.85 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG/SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515580_2 CDM 260 RC 96367 HCPCS outpatient 263 197.25 MOLINA MCR ADV MOLINA MCR ADV 234.07 89 999999999 205.14 249.85 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG/SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515580_2 CDM 260 RC 96367 HCPCS outpatient 263 197.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 234.07 89 999999999 205.14 249.85 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG/SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515580_2 CDM 260 RC 96367 HCPCS outpatient 263 197.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 234.07 89 999999999 205.14 249.85 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG/SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515580_2 CDM 260 RC 96367 HCPCS outpatient 263 197.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 236.7 90 999999999 205.14 249.85 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG/SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515580_2 CDM 260 RC 96367 HCPCS outpatient 263 197.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 249.85 95 999999999 205.14 249.85 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG/SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515580_2 CDM 260 RC 96367 HCPCS outpatient 263 197.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 249.85 95 999999999 205.14 249.85 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG/SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515580_2 CDM 260 RC 96367 HCPCS outpatient 263 197.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 234.07 89 999999999 205.14 249.85 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG/SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515580_2 CDM 260 RC 96367 HCPCS outpatient 263 197.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 231.44 88 999999999 205.14 249.85 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG/SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515580_2 CDM 260 RC 96367 HCPCS outpatient 263 197.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 234.07 89 999999999 205.14 249.85 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); CONCURRENT INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515581_1 CDM 260 RC 96368 HCPCS outpatient 224 168 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 201.6 90 999999999 174.72 212.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); CONCURRENT INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515581_1 CDM 260 RC 96368 HCPCS outpatient 224 168 AETNA MCR ADV AETNA MCR ADV 174.72 78 999999999 174.72 212.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); CONCURRENT INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515581_1 CDM 260 RC 96368 HCPCS outpatient 224 168 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 196.16 87.57 999999999 174.72 212.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); CONCURRENT INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515581_1 CDM 260 RC 96368 HCPCS outpatient 224 168 COORDINATED CARE MCAID COORDINATED CARE MCAID 190.56 85.07 999999999 174.72 212.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); CONCURRENT INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515581_1 CDM 260 RC 96368 HCPCS outpatient 224 168 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 190.56 85.07 999999999 174.72 212.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); CONCURRENT INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515581_1 CDM 260 RC 96368 HCPCS outpatient 224 168 MOLINA MCAID MOLINA MCAID 186.82 83.4 999999999 174.72 212.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); CONCURRENT INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515581_1 CDM 260 RC 96368 HCPCS outpatient 224 168 MOLINA MCR ADV MOLINA MCR ADV 199.36 89 999999999 174.72 212.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); CONCURRENT INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515581_1 CDM 260 RC 96368 HCPCS outpatient 224 168 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 199.36 89 999999999 174.72 212.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); CONCURRENT INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515581_1 CDM 260 RC 96368 HCPCS outpatient 224 168 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 199.36 89 999999999 174.72 212.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); CONCURRENT INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515581_1 CDM 260 RC 96368 HCPCS outpatient 224 168 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 201.6 90 999999999 174.72 212.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); CONCURRENT INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515581_1 CDM 260 RC 96368 HCPCS outpatient 224 168 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 212.8 95 999999999 174.72 212.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); CONCURRENT INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515581_1 CDM 260 RC 96368 HCPCS outpatient 224 168 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 212.8 95 999999999 174.72 212.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); CONCURRENT INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515581_1 CDM 260 RC 96368 HCPCS outpatient 224 168 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 199.36 89 999999999 174.72 212.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); CONCURRENT INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515581_1 CDM 260 RC 96368 HCPCS outpatient 224 168 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 197.12 88 999999999 174.72 212.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); CONCURRENT INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515581_1 CDM 260 RC 96368 HCPCS outpatient 224 168 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 199.36 89 999999999 174.72 212.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); CONCURRENT INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515581_2 CDM 260 RC 96368 HCPCS outpatient 224 168 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 201.6 90 999999999 174.72 212.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); CONCURRENT INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515581_2 CDM 260 RC 96368 HCPCS outpatient 224 168 AETNA MCR ADV AETNA MCR ADV 174.72 78 999999999 174.72 212.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); CONCURRENT INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515581_2 CDM 260 RC 96368 HCPCS outpatient 224 168 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 196.16 87.57 999999999 174.72 212.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); CONCURRENT INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515581_2 CDM 260 RC 96368 HCPCS outpatient 224 168 COORDINATED CARE MCAID COORDINATED CARE MCAID 190.56 85.07 999999999 174.72 212.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); CONCURRENT INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515581_2 CDM 260 RC 96368 HCPCS outpatient 224 168 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 190.56 85.07 999999999 174.72 212.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); CONCURRENT INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515581_2 CDM 260 RC 96368 HCPCS outpatient 224 168 MOLINA MCAID MOLINA MCAID 186.82 83.4 999999999 174.72 212.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); CONCURRENT INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515581_2 CDM 260 RC 96368 HCPCS outpatient 224 168 MOLINA MCR ADV MOLINA MCR ADV 199.36 89 999999999 174.72 212.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); CONCURRENT INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515581_2 CDM 260 RC 96368 HCPCS outpatient 224 168 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 199.36 89 999999999 174.72 212.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); CONCURRENT INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515581_2 CDM 260 RC 96368 HCPCS outpatient 224 168 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 199.36 89 999999999 174.72 212.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); CONCURRENT INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515581_2 CDM 260 RC 96368 HCPCS outpatient 224 168 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 201.6 90 999999999 174.72 212.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); CONCURRENT INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515581_2 CDM 260 RC 96368 HCPCS outpatient 224 168 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 212.8 95 999999999 174.72 212.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); CONCURRENT INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515581_2 CDM 260 RC 96368 HCPCS outpatient 224 168 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 212.8 95 999999999 174.72 212.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); CONCURRENT INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515581_2 CDM 260 RC 96368 HCPCS outpatient 224 168 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 199.36 89 999999999 174.72 212.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); CONCURRENT INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515581_2 CDM 260 RC 96368 HCPCS outpatient 224 168 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 197.12 88 999999999 174.72 212.8 percent of total billed charges "INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); CONCURRENT INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515581_2 CDM 260 RC 96368 HCPCS outpatient 224 168 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 199.36 89 999999999 174.72 212.8 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 9515582_1 CDM 260 RC 96374 HCPCS outpatient 302 226.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 271.8 90 999999999 235.56 286.9 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 9515582_1 CDM 260 RC 96374 HCPCS outpatient 302 226.5 AETNA MCR ADV AETNA MCR ADV 235.56 78 999999999 235.56 286.9 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 9515582_1 CDM 260 RC 96374 HCPCS outpatient 302 226.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 264.46 87.57 999999999 235.56 286.9 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 9515582_1 CDM 260 RC 96374 HCPCS outpatient 302 226.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 256.91 85.07 999999999 235.56 286.9 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 9515582_1 CDM 260 RC 96374 HCPCS outpatient 302 226.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 256.91 85.07 999999999 235.56 286.9 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 9515582_1 CDM 260 RC 96374 HCPCS outpatient 302 226.5 MOLINA MCAID MOLINA MCAID 251.87 83.4 999999999 235.56 286.9 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 9515582_1 CDM 260 RC 96374 HCPCS outpatient 302 226.5 MOLINA MCR ADV MOLINA MCR ADV 268.78 89 999999999 235.56 286.9 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 9515582_1 CDM 260 RC 96374 HCPCS outpatient 302 226.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 268.78 89 999999999 235.56 286.9 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 9515582_1 CDM 260 RC 96374 HCPCS outpatient 302 226.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 268.78 89 999999999 235.56 286.9 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 9515582_1 CDM 260 RC 96374 HCPCS outpatient 302 226.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 271.8 90 999999999 235.56 286.9 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 9515582_1 CDM 260 RC 96374 HCPCS outpatient 302 226.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 286.9 95 999999999 235.56 286.9 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 9515582_1 CDM 260 RC 96374 HCPCS outpatient 302 226.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 286.9 95 999999999 235.56 286.9 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 9515582_1 CDM 260 RC 96374 HCPCS outpatient 302 226.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 268.78 89 999999999 235.56 286.9 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 9515582_1 CDM 260 RC 96374 HCPCS outpatient 302 226.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 265.76 88 999999999 235.56 286.9 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 9515582_1 CDM 260 RC 96374 HCPCS outpatient 302 226.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 268.78 89 999999999 235.56 286.9 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 9515582_2 CDM 260 RC 96374 HCPCS outpatient 302 226.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 271.8 90 999999999 235.56 286.9 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 9515582_2 CDM 260 RC 96374 HCPCS outpatient 302 226.5 AETNA MCR ADV AETNA MCR ADV 235.56 78 999999999 235.56 286.9 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 9515582_2 CDM 260 RC 96374 HCPCS outpatient 302 226.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 264.46 87.57 999999999 235.56 286.9 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 9515582_2 CDM 260 RC 96374 HCPCS outpatient 302 226.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 256.91 85.07 999999999 235.56 286.9 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 9515582_2 CDM 260 RC 96374 HCPCS outpatient 302 226.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 256.91 85.07 999999999 235.56 286.9 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 9515582_2 CDM 260 RC 96374 HCPCS outpatient 302 226.5 MOLINA MCAID MOLINA MCAID 251.87 83.4 999999999 235.56 286.9 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 9515582_2 CDM 260 RC 96374 HCPCS outpatient 302 226.5 MOLINA MCR ADV MOLINA MCR ADV 268.78 89 999999999 235.56 286.9 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 9515582_2 CDM 260 RC 96374 HCPCS outpatient 302 226.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 268.78 89 999999999 235.56 286.9 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 9515582_2 CDM 260 RC 96374 HCPCS outpatient 302 226.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 268.78 89 999999999 235.56 286.9 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 9515582_2 CDM 260 RC 96374 HCPCS outpatient 302 226.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 271.8 90 999999999 235.56 286.9 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 9515582_2 CDM 260 RC 96374 HCPCS outpatient 302 226.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 286.9 95 999999999 235.56 286.9 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 9515582_2 CDM 260 RC 96374 HCPCS outpatient 302 226.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 286.9 95 999999999 235.56 286.9 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 9515582_2 CDM 260 RC 96374 HCPCS outpatient 302 226.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 268.78 89 999999999 235.56 286.9 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 9515582_2 CDM 260 RC 96374 HCPCS outpatient 302 226.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 265.76 88 999999999 235.56 286.9 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 9515582_2 CDM 260 RC 96374 HCPCS outpatient 302 226.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 268.78 89 999999999 235.56 286.9 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF A NEW SUBSTANCE/DRUG (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515583_1 CDM 260 RC 96375 HCPCS outpatient 165 123.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 148.5 90 999999999 128.7 156.75 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF A NEW SUBSTANCE/DRUG (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515583_1 CDM 260 RC 96375 HCPCS outpatient 165 123.75 AETNA MCR ADV AETNA MCR ADV 128.7 78 999999999 128.7 156.75 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF A NEW SUBSTANCE/DRUG (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515583_1 CDM 260 RC 96375 HCPCS outpatient 165 123.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 144.49 87.57 999999999 128.7 156.75 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF A NEW SUBSTANCE/DRUG (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515583_1 CDM 260 RC 96375 HCPCS outpatient 165 123.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 140.37 85.07 999999999 128.7 156.75 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF A NEW SUBSTANCE/DRUG (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515583_1 CDM 260 RC 96375 HCPCS outpatient 165 123.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 140.37 85.07 999999999 128.7 156.75 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF A NEW SUBSTANCE/DRUG (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515583_1 CDM 260 RC 96375 HCPCS outpatient 165 123.75 MOLINA MCAID MOLINA MCAID 137.61 83.4 999999999 128.7 156.75 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF A NEW SUBSTANCE/DRUG (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515583_1 CDM 260 RC 96375 HCPCS outpatient 165 123.75 MOLINA MCR ADV MOLINA MCR ADV 146.85 89 999999999 128.7 156.75 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF A NEW SUBSTANCE/DRUG (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515583_1 CDM 260 RC 96375 HCPCS outpatient 165 123.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 146.85 89 999999999 128.7 156.75 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF A NEW SUBSTANCE/DRUG (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515583_1 CDM 260 RC 96375 HCPCS outpatient 165 123.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 146.85 89 999999999 128.7 156.75 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF A NEW SUBSTANCE/DRUG (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515583_1 CDM 260 RC 96375 HCPCS outpatient 165 123.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 148.5 90 999999999 128.7 156.75 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF A NEW SUBSTANCE/DRUG (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515583_1 CDM 260 RC 96375 HCPCS outpatient 165 123.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 156.75 95 999999999 128.7 156.75 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF A NEW SUBSTANCE/DRUG (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515583_1 CDM 260 RC 96375 HCPCS outpatient 165 123.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 156.75 95 999999999 128.7 156.75 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF A NEW SUBSTANCE/DRUG (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515583_1 CDM 260 RC 96375 HCPCS outpatient 165 123.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 146.85 89 999999999 128.7 156.75 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF A NEW SUBSTANCE/DRUG (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515583_1 CDM 260 RC 96375 HCPCS outpatient 165 123.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 145.2 88 999999999 128.7 156.75 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF A NEW SUBSTANCE/DRUG (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515583_1 CDM 260 RC 96375 HCPCS outpatient 165 123.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 146.85 89 999999999 128.7 156.75 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF A NEW SUBSTANCE/DRUG (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515583_2 CDM 260 RC 96375 HCPCS outpatient 165 123.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 148.5 90 999999999 128.7 156.75 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF A NEW SUBSTANCE/DRUG (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515583_2 CDM 260 RC 96375 HCPCS outpatient 165 123.75 AETNA MCR ADV AETNA MCR ADV 128.7 78 999999999 128.7 156.75 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF A NEW SUBSTANCE/DRUG (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515583_2 CDM 260 RC 96375 HCPCS outpatient 165 123.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 144.49 87.57 999999999 128.7 156.75 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF A NEW SUBSTANCE/DRUG (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515583_2 CDM 260 RC 96375 HCPCS outpatient 165 123.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 140.37 85.07 999999999 128.7 156.75 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF A NEW SUBSTANCE/DRUG (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515583_2 CDM 260 RC 96375 HCPCS outpatient 165 123.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 140.37 85.07 999999999 128.7 156.75 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF A NEW SUBSTANCE/DRUG (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515583_2 CDM 260 RC 96375 HCPCS outpatient 165 123.75 MOLINA MCAID MOLINA MCAID 137.61 83.4 999999999 128.7 156.75 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF A NEW SUBSTANCE/DRUG (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515583_2 CDM 260 RC 96375 HCPCS outpatient 165 123.75 MOLINA MCR ADV MOLINA MCR ADV 146.85 89 999999999 128.7 156.75 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF A NEW SUBSTANCE/DRUG (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515583_2 CDM 260 RC 96375 HCPCS outpatient 165 123.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 146.85 89 999999999 128.7 156.75 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF A NEW SUBSTANCE/DRUG (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515583_2 CDM 260 RC 96375 HCPCS outpatient 165 123.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 146.85 89 999999999 128.7 156.75 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF A NEW SUBSTANCE/DRUG (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515583_2 CDM 260 RC 96375 HCPCS outpatient 165 123.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 148.5 90 999999999 128.7 156.75 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF A NEW SUBSTANCE/DRUG (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515583_2 CDM 260 RC 96375 HCPCS outpatient 165 123.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 156.75 95 999999999 128.7 156.75 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF A NEW SUBSTANCE/DRUG (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515583_2 CDM 260 RC 96375 HCPCS outpatient 165 123.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 156.75 95 999999999 128.7 156.75 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF A NEW SUBSTANCE/DRUG (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515583_2 CDM 260 RC 96375 HCPCS outpatient 165 123.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 146.85 89 999999999 128.7 156.75 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF A NEW SUBSTANCE/DRUG (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515583_2 CDM 260 RC 96375 HCPCS outpatient 165 123.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 145.2 88 999999999 128.7 156.75 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF A NEW SUBSTANCE/DRUG (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515583_2 CDM 260 RC 96375 HCPCS outpatient 165 123.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 146.85 89 999999999 128.7 156.75 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF THE SAME SUBSTANCE/DRUG PROVIDED IN A FACILITY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515584_1 CDM 260 RC 96376 HCPCS outpatient 159 119.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 143.1 90 999999999 124.02 151.05 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF THE SAME SUBSTANCE/DRUG PROVIDED IN A FACILITY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515584_1 CDM 260 RC 96376 HCPCS outpatient 159 119.25 AETNA MCR ADV AETNA MCR ADV 124.02 78 999999999 124.02 151.05 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF THE SAME SUBSTANCE/DRUG PROVIDED IN A FACILITY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515584_1 CDM 260 RC 96376 HCPCS outpatient 159 119.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 139.24 87.57 999999999 124.02 151.05 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF THE SAME SUBSTANCE/DRUG PROVIDED IN A FACILITY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515584_1 CDM 260 RC 96376 HCPCS outpatient 159 119.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 135.26 85.07 999999999 124.02 151.05 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF THE SAME SUBSTANCE/DRUG PROVIDED IN A FACILITY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515584_1 CDM 260 RC 96376 HCPCS outpatient 159 119.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 135.26 85.07 999999999 124.02 151.05 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF THE SAME SUBSTANCE/DRUG PROVIDED IN A FACILITY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515584_1 CDM 260 RC 96376 HCPCS outpatient 159 119.25 MOLINA MCAID MOLINA MCAID 132.61 83.4 999999999 124.02 151.05 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF THE SAME SUBSTANCE/DRUG PROVIDED IN A FACILITY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515584_1 CDM 260 RC 96376 HCPCS outpatient 159 119.25 MOLINA MCR ADV MOLINA MCR ADV 141.51 89 999999999 124.02 151.05 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF THE SAME SUBSTANCE/DRUG PROVIDED IN A FACILITY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515584_1 CDM 260 RC 96376 HCPCS outpatient 159 119.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 141.51 89 999999999 124.02 151.05 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF THE SAME SUBSTANCE/DRUG PROVIDED IN A FACILITY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515584_1 CDM 260 RC 96376 HCPCS outpatient 159 119.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 141.51 89 999999999 124.02 151.05 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF THE SAME SUBSTANCE/DRUG PROVIDED IN A FACILITY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515584_1 CDM 260 RC 96376 HCPCS outpatient 159 119.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 143.1 90 999999999 124.02 151.05 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF THE SAME SUBSTANCE/DRUG PROVIDED IN A FACILITY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515584_1 CDM 260 RC 96376 HCPCS outpatient 159 119.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 151.05 95 999999999 124.02 151.05 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF THE SAME SUBSTANCE/DRUG PROVIDED IN A FACILITY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515584_1 CDM 260 RC 96376 HCPCS outpatient 159 119.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 151.05 95 999999999 124.02 151.05 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF THE SAME SUBSTANCE/DRUG PROVIDED IN A FACILITY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515584_1 CDM 260 RC 96376 HCPCS outpatient 159 119.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 141.51 89 999999999 124.02 151.05 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF THE SAME SUBSTANCE/DRUG PROVIDED IN A FACILITY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515584_1 CDM 260 RC 96376 HCPCS outpatient 159 119.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 139.92 88 999999999 124.02 151.05 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF THE SAME SUBSTANCE/DRUG PROVIDED IN A FACILITY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515584_1 CDM 260 RC 96376 HCPCS outpatient 159 119.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 141.51 89 999999999 124.02 151.05 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF THE SAME SUBSTANCE/DRUG PROVIDED IN A FACILITY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515584_2 CDM 260 RC 96376 HCPCS outpatient 159 119.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 143.1 90 999999999 124.02 151.05 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF THE SAME SUBSTANCE/DRUG PROVIDED IN A FACILITY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515584_2 CDM 260 RC 96376 HCPCS outpatient 159 119.25 AETNA MCR ADV AETNA MCR ADV 124.02 78 999999999 124.02 151.05 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF THE SAME SUBSTANCE/DRUG PROVIDED IN A FACILITY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515584_2 CDM 260 RC 96376 HCPCS outpatient 159 119.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 139.24 87.57 999999999 124.02 151.05 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF THE SAME SUBSTANCE/DRUG PROVIDED IN A FACILITY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515584_2 CDM 260 RC 96376 HCPCS outpatient 159 119.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 135.26 85.07 999999999 124.02 151.05 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF THE SAME SUBSTANCE/DRUG PROVIDED IN A FACILITY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515584_2 CDM 260 RC 96376 HCPCS outpatient 159 119.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 135.26 85.07 999999999 124.02 151.05 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF THE SAME SUBSTANCE/DRUG PROVIDED IN A FACILITY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515584_2 CDM 260 RC 96376 HCPCS outpatient 159 119.25 MOLINA MCAID MOLINA MCAID 132.61 83.4 999999999 124.02 151.05 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF THE SAME SUBSTANCE/DRUG PROVIDED IN A FACILITY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515584_2 CDM 260 RC 96376 HCPCS outpatient 159 119.25 MOLINA MCR ADV MOLINA MCR ADV 141.51 89 999999999 124.02 151.05 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF THE SAME SUBSTANCE/DRUG PROVIDED IN A FACILITY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515584_2 CDM 260 RC 96376 HCPCS outpatient 159 119.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 141.51 89 999999999 124.02 151.05 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF THE SAME SUBSTANCE/DRUG PROVIDED IN A FACILITY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515584_2 CDM 260 RC 96376 HCPCS outpatient 159 119.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 141.51 89 999999999 124.02 151.05 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF THE SAME SUBSTANCE/DRUG PROVIDED IN A FACILITY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515584_2 CDM 260 RC 96376 HCPCS outpatient 159 119.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 143.1 90 999999999 124.02 151.05 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF THE SAME SUBSTANCE/DRUG PROVIDED IN A FACILITY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515584_2 CDM 260 RC 96376 HCPCS outpatient 159 119.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 151.05 95 999999999 124.02 151.05 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF THE SAME SUBSTANCE/DRUG PROVIDED IN A FACILITY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515584_2 CDM 260 RC 96376 HCPCS outpatient 159 119.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 151.05 95 999999999 124.02 151.05 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF THE SAME SUBSTANCE/DRUG PROVIDED IN A FACILITY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515584_2 CDM 260 RC 96376 HCPCS outpatient 159 119.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 141.51 89 999999999 124.02 151.05 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF THE SAME SUBSTANCE/DRUG PROVIDED IN A FACILITY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515584_2 CDM 260 RC 96376 HCPCS outpatient 159 119.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 139.92 88 999999999 124.02 151.05 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF THE SAME SUBSTANCE/DRUG PROVIDED IN A FACILITY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515584_2 CDM 260 RC 96376 HCPCS outpatient 159 119.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 141.51 89 999999999 124.02 151.05 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; INITIAL, 31 MINUTES TO 1 HOUR" 9515585_1 CDM 260 RC 96360 HCPCS outpatient 400 300 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 360 90 999999999 312 380 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; INITIAL, 31 MINUTES TO 1 HOUR" 9515585_1 CDM 260 RC 96360 HCPCS outpatient 400 300 AETNA MCR ADV AETNA MCR ADV 312 78 999999999 312 380 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; INITIAL, 31 MINUTES TO 1 HOUR" 9515585_1 CDM 260 RC 96360 HCPCS outpatient 400 300 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 350.28 87.57 999999999 312 380 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; INITIAL, 31 MINUTES TO 1 HOUR" 9515585_1 CDM 260 RC 96360 HCPCS outpatient 400 300 COORDINATED CARE MCAID COORDINATED CARE MCAID 340.28 85.07 999999999 312 380 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; INITIAL, 31 MINUTES TO 1 HOUR" 9515585_1 CDM 260 RC 96360 HCPCS outpatient 400 300 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 340.28 85.07 999999999 312 380 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; INITIAL, 31 MINUTES TO 1 HOUR" 9515585_1 CDM 260 RC 96360 HCPCS outpatient 400 300 MOLINA MCAID MOLINA MCAID 333.6 83.4 999999999 312 380 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; INITIAL, 31 MINUTES TO 1 HOUR" 9515585_1 CDM 260 RC 96360 HCPCS outpatient 400 300 MOLINA MCR ADV MOLINA MCR ADV 356 89 999999999 312 380 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; INITIAL, 31 MINUTES TO 1 HOUR" 9515585_1 CDM 260 RC 96360 HCPCS outpatient 400 300 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 356 89 999999999 312 380 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; INITIAL, 31 MINUTES TO 1 HOUR" 9515585_1 CDM 260 RC 96360 HCPCS outpatient 400 300 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 356 89 999999999 312 380 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; INITIAL, 31 MINUTES TO 1 HOUR" 9515585_1 CDM 260 RC 96360 HCPCS outpatient 400 300 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 360 90 999999999 312 380 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; INITIAL, 31 MINUTES TO 1 HOUR" 9515585_1 CDM 260 RC 96360 HCPCS outpatient 400 300 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 380 95 999999999 312 380 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; INITIAL, 31 MINUTES TO 1 HOUR" 9515585_1 CDM 260 RC 96360 HCPCS outpatient 400 300 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 380 95 999999999 312 380 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; INITIAL, 31 MINUTES TO 1 HOUR" 9515585_1 CDM 260 RC 96360 HCPCS outpatient 400 300 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 356 89 999999999 312 380 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; INITIAL, 31 MINUTES TO 1 HOUR" 9515585_1 CDM 260 RC 96360 HCPCS outpatient 400 300 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 352 88 999999999 312 380 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; INITIAL, 31 MINUTES TO 1 HOUR" 9515585_1 CDM 260 RC 96360 HCPCS outpatient 400 300 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 356 89 999999999 312 380 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; INITIAL, 31 MINUTES TO 1 HOUR" 9515585_2 CDM 260 RC 96360 HCPCS outpatient 400 300 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 360 90 999999999 312 380 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; INITIAL, 31 MINUTES TO 1 HOUR" 9515585_2 CDM 260 RC 96360 HCPCS outpatient 400 300 AETNA MCR ADV AETNA MCR ADV 312 78 999999999 312 380 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; INITIAL, 31 MINUTES TO 1 HOUR" 9515585_2 CDM 260 RC 96360 HCPCS outpatient 400 300 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 350.28 87.57 999999999 312 380 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; INITIAL, 31 MINUTES TO 1 HOUR" 9515585_2 CDM 260 RC 96360 HCPCS outpatient 400 300 COORDINATED CARE MCAID COORDINATED CARE MCAID 340.28 85.07 999999999 312 380 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; INITIAL, 31 MINUTES TO 1 HOUR" 9515585_2 CDM 260 RC 96360 HCPCS outpatient 400 300 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 340.28 85.07 999999999 312 380 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; INITIAL, 31 MINUTES TO 1 HOUR" 9515585_2 CDM 260 RC 96360 HCPCS outpatient 400 300 MOLINA MCAID MOLINA MCAID 333.6 83.4 999999999 312 380 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; INITIAL, 31 MINUTES TO 1 HOUR" 9515585_2 CDM 260 RC 96360 HCPCS outpatient 400 300 MOLINA MCR ADV MOLINA MCR ADV 356 89 999999999 312 380 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; INITIAL, 31 MINUTES TO 1 HOUR" 9515585_2 CDM 260 RC 96360 HCPCS outpatient 400 300 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 356 89 999999999 312 380 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; INITIAL, 31 MINUTES TO 1 HOUR" 9515585_2 CDM 260 RC 96360 HCPCS outpatient 400 300 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 356 89 999999999 312 380 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; INITIAL, 31 MINUTES TO 1 HOUR" 9515585_2 CDM 260 RC 96360 HCPCS outpatient 400 300 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 360 90 999999999 312 380 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; INITIAL, 31 MINUTES TO 1 HOUR" 9515585_2 CDM 260 RC 96360 HCPCS outpatient 400 300 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 380 95 999999999 312 380 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; INITIAL, 31 MINUTES TO 1 HOUR" 9515585_2 CDM 260 RC 96360 HCPCS outpatient 400 300 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 380 95 999999999 312 380 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; INITIAL, 31 MINUTES TO 1 HOUR" 9515585_2 CDM 260 RC 96360 HCPCS outpatient 400 300 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 356 89 999999999 312 380 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; INITIAL, 31 MINUTES TO 1 HOUR" 9515585_2 CDM 260 RC 96360 HCPCS outpatient 400 300 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 352 88 999999999 312 380 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; INITIAL, 31 MINUTES TO 1 HOUR" 9515585_2 CDM 260 RC 96360 HCPCS outpatient 400 300 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 356 89 999999999 312 380 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515586_1 CDM 260 RC 96361 HCPCS outpatient 146 109.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 131.4 90 999999999 113.88 138.7 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515586_1 CDM 260 RC 96361 HCPCS outpatient 146 109.5 AETNA MCR ADV AETNA MCR ADV 113.88 78 999999999 113.88 138.7 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515586_1 CDM 260 RC 96361 HCPCS outpatient 146 109.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 127.85 87.57 999999999 113.88 138.7 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515586_1 CDM 260 RC 96361 HCPCS outpatient 146 109.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 124.2 85.07 999999999 113.88 138.7 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515586_1 CDM 260 RC 96361 HCPCS outpatient 146 109.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 124.2 85.07 999999999 113.88 138.7 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515586_1 CDM 260 RC 96361 HCPCS outpatient 146 109.5 MOLINA MCAID MOLINA MCAID 121.76 83.4 999999999 113.88 138.7 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515586_1 CDM 260 RC 96361 HCPCS outpatient 146 109.5 MOLINA MCR ADV MOLINA MCR ADV 129.94 89 999999999 113.88 138.7 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515586_1 CDM 260 RC 96361 HCPCS outpatient 146 109.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 129.94 89 999999999 113.88 138.7 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515586_1 CDM 260 RC 96361 HCPCS outpatient 146 109.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 129.94 89 999999999 113.88 138.7 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515586_1 CDM 260 RC 96361 HCPCS outpatient 146 109.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 131.4 90 999999999 113.88 138.7 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515586_1 CDM 260 RC 96361 HCPCS outpatient 146 109.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 138.7 95 999999999 113.88 138.7 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515586_1 CDM 260 RC 96361 HCPCS outpatient 146 109.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 138.7 95 999999999 113.88 138.7 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515586_1 CDM 260 RC 96361 HCPCS outpatient 146 109.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 129.94 89 999999999 113.88 138.7 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515586_1 CDM 260 RC 96361 HCPCS outpatient 146 109.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 128.48 88 999999999 113.88 138.7 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515586_1 CDM 260 RC 96361 HCPCS outpatient 146 109.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 129.94 89 999999999 113.88 138.7 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515586_2 CDM 260 RC 96361 HCPCS outpatient 146 109.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 131.4 90 999999999 113.88 138.7 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515586_2 CDM 260 RC 96361 HCPCS outpatient 146 109.5 AETNA MCR ADV AETNA MCR ADV 113.88 78 999999999 113.88 138.7 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515586_2 CDM 260 RC 96361 HCPCS outpatient 146 109.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 127.85 87.57 999999999 113.88 138.7 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515586_2 CDM 260 RC 96361 HCPCS outpatient 146 109.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 124.2 85.07 999999999 113.88 138.7 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515586_2 CDM 260 RC 96361 HCPCS outpatient 146 109.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 124.2 85.07 999999999 113.88 138.7 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515586_2 CDM 260 RC 96361 HCPCS outpatient 146 109.5 MOLINA MCAID MOLINA MCAID 121.76 83.4 999999999 113.88 138.7 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515586_2 CDM 260 RC 96361 HCPCS outpatient 146 109.5 MOLINA MCR ADV MOLINA MCR ADV 129.94 89 999999999 113.88 138.7 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515586_2 CDM 260 RC 96361 HCPCS outpatient 146 109.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 129.94 89 999999999 113.88 138.7 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515586_2 CDM 260 RC 96361 HCPCS outpatient 146 109.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 129.94 89 999999999 113.88 138.7 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515586_2 CDM 260 RC 96361 HCPCS outpatient 146 109.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 131.4 90 999999999 113.88 138.7 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515586_2 CDM 260 RC 96361 HCPCS outpatient 146 109.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 138.7 95 999999999 113.88 138.7 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515586_2 CDM 260 RC 96361 HCPCS outpatient 146 109.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 138.7 95 999999999 113.88 138.7 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515586_2 CDM 260 RC 96361 HCPCS outpatient 146 109.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 129.94 89 999999999 113.88 138.7 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515586_2 CDM 260 RC 96361 HCPCS outpatient 146 109.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 128.48 88 999999999 113.88 138.7 percent of total billed charges "INTRAVENOUS INFUSION, HYDRATION; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9515586_2 CDM 260 RC 96361 HCPCS outpatient 146 109.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 129.94 89 999999999 113.88 138.7 percent of total billed charges "TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACCINE (TDAP), WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 9515595_1 CDM 636 RC 90715 HCPCS outpatient 140 105 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 126 90 999999999 109.2 133 percent of total billed charges "TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACCINE (TDAP), WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 9515595_1 CDM 636 RC 90715 HCPCS outpatient 140 105 AETNA MCR ADV AETNA MCR ADV 109.2 78 999999999 109.2 133 percent of total billed charges "TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACCINE (TDAP), WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 9515595_1 CDM 636 RC 90715 HCPCS outpatient 140 105 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 122.6 87.57 999999999 109.2 133 percent of total billed charges "TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACCINE (TDAP), WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 9515595_1 CDM 636 RC 90715 HCPCS outpatient 140 105 COORDINATED CARE MCAID COORDINATED CARE MCAID 119.1 85.07 999999999 109.2 133 percent of total billed charges "TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACCINE (TDAP), WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 9515595_1 CDM 636 RC 90715 HCPCS outpatient 140 105 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 119.1 85.07 999999999 109.2 133 percent of total billed charges "TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACCINE (TDAP), WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 9515595_1 CDM 636 RC 90715 HCPCS outpatient 140 105 MOLINA MCAID MOLINA MCAID 116.76 83.4 999999999 109.2 133 percent of total billed charges "TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACCINE (TDAP), WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 9515595_1 CDM 636 RC 90715 HCPCS outpatient 140 105 MOLINA MCR ADV MOLINA MCR ADV 124.6 89 999999999 109.2 133 percent of total billed charges "TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACCINE (TDAP), WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 9515595_1 CDM 636 RC 90715 HCPCS outpatient 140 105 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 124.6 89 999999999 109.2 133 percent of total billed charges "TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACCINE (TDAP), WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 9515595_1 CDM 636 RC 90715 HCPCS outpatient 140 105 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 124.6 89 999999999 109.2 133 percent of total billed charges "TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACCINE (TDAP), WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 9515595_1 CDM 636 RC 90715 HCPCS outpatient 140 105 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 126 90 999999999 109.2 133 percent of total billed charges "TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACCINE (TDAP), WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 9515595_1 CDM 636 RC 90715 HCPCS outpatient 140 105 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 133 95 999999999 109.2 133 percent of total billed charges "TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACCINE (TDAP), WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 9515595_1 CDM 636 RC 90715 HCPCS outpatient 140 105 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 133 95 999999999 109.2 133 percent of total billed charges "TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACCINE (TDAP), WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 9515595_1 CDM 636 RC 90715 HCPCS outpatient 140 105 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 124.6 89 999999999 109.2 133 percent of total billed charges "TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACCINE (TDAP), WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 9515595_1 CDM 636 RC 90715 HCPCS outpatient 140 105 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 123.2 88 999999999 109.2 133 percent of total billed charges "TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACCINE (TDAP), WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE" 9515595_1 CDM 636 RC 90715 HCPCS outpatient 140 105 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 124.6 89 999999999 109.2 133 percent of total billed charges "INJECTION, BETAMETHASONE ACETATE 3 MG AND BETAMETHASONE SODIUM PHOSPHATE 3 MG" 9515596_1 CDM 636 RC J0702 HCPCS outpatient 32 24 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 28.8 90 999999999 24.96 30.4 percent of total billed charges "INJECTION, BETAMETHASONE ACETATE 3 MG AND BETAMETHASONE SODIUM PHOSPHATE 3 MG" 9515596_1 CDM 636 RC J0702 HCPCS outpatient 32 24 AETNA MCR ADV AETNA MCR ADV 24.96 78 999999999 24.96 30.4 percent of total billed charges "INJECTION, BETAMETHASONE ACETATE 3 MG AND BETAMETHASONE SODIUM PHOSPHATE 3 MG" 9515596_1 CDM 636 RC J0702 HCPCS outpatient 32 24 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 28.02 87.57 999999999 24.96 30.4 percent of total billed charges "INJECTION, BETAMETHASONE ACETATE 3 MG AND BETAMETHASONE SODIUM PHOSPHATE 3 MG" 9515596_1 CDM 636 RC J0702 HCPCS outpatient 32 24 COORDINATED CARE MCAID COORDINATED CARE MCAID 27.22 85.07 999999999 24.96 30.4 percent of total billed charges "INJECTION, BETAMETHASONE ACETATE 3 MG AND BETAMETHASONE SODIUM PHOSPHATE 3 MG" 9515596_1 CDM 636 RC J0702 HCPCS outpatient 32 24 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 27.22 85.07 999999999 24.96 30.4 percent of total billed charges "INJECTION, BETAMETHASONE ACETATE 3 MG AND BETAMETHASONE SODIUM PHOSPHATE 3 MG" 9515596_1 CDM 636 RC J0702 HCPCS outpatient 32 24 MOLINA MCAID MOLINA MCAID 26.69 83.4 999999999 24.96 30.4 percent of total billed charges "INJECTION, BETAMETHASONE ACETATE 3 MG AND BETAMETHASONE SODIUM PHOSPHATE 3 MG" 9515596_1 CDM 636 RC J0702 HCPCS outpatient 32 24 MOLINA MCR ADV MOLINA MCR ADV 28.48 89 999999999 24.96 30.4 percent of total billed charges "INJECTION, BETAMETHASONE ACETATE 3 MG AND BETAMETHASONE SODIUM PHOSPHATE 3 MG" 9515596_1 CDM 636 RC J0702 HCPCS outpatient 32 24 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 28.48 89 999999999 24.96 30.4 percent of total billed charges "INJECTION, BETAMETHASONE ACETATE 3 MG AND BETAMETHASONE SODIUM PHOSPHATE 3 MG" 9515596_1 CDM 636 RC J0702 HCPCS outpatient 32 24 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 28.48 89 999999999 24.96 30.4 percent of total billed charges "INJECTION, BETAMETHASONE ACETATE 3 MG AND BETAMETHASONE SODIUM PHOSPHATE 3 MG" 9515596_1 CDM 636 RC J0702 HCPCS outpatient 32 24 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 28.8 90 999999999 24.96 30.4 percent of total billed charges "INJECTION, BETAMETHASONE ACETATE 3 MG AND BETAMETHASONE SODIUM PHOSPHATE 3 MG" 9515596_1 CDM 636 RC J0702 HCPCS outpatient 32 24 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 30.4 95 999999999 24.96 30.4 percent of total billed charges "INJECTION, BETAMETHASONE ACETATE 3 MG AND BETAMETHASONE SODIUM PHOSPHATE 3 MG" 9515596_1 CDM 636 RC J0702 HCPCS outpatient 32 24 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 30.4 95 999999999 24.96 30.4 percent of total billed charges "INJECTION, BETAMETHASONE ACETATE 3 MG AND BETAMETHASONE SODIUM PHOSPHATE 3 MG" 9515596_1 CDM 636 RC J0702 HCPCS outpatient 32 24 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 28.48 89 999999999 24.96 30.4 percent of total billed charges "INJECTION, BETAMETHASONE ACETATE 3 MG AND BETAMETHASONE SODIUM PHOSPHATE 3 MG" 9515596_1 CDM 636 RC J0702 HCPCS outpatient 32 24 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 28.16 88 999999999 24.96 30.4 percent of total billed charges "INJECTION, BETAMETHASONE ACETATE 3 MG AND BETAMETHASONE SODIUM PHOSPHATE 3 MG" 9515596_1 CDM 636 RC J0702 HCPCS outpatient 32 24 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 28.48 89 999999999 24.96 30.4 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9515607_1 CDM 361 RC 12032 HCPCS outpatient 585 438.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 526.5 999999999 456.3 555.75 case rate "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9515607_1 CDM 361 RC 12032 HCPCS outpatient 585 438.75 AETNA MCR ADV AETNA MCR ADV 456.3 78 999999999 456.3 555.75 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9515607_1 CDM 361 RC 12032 HCPCS outpatient 585 438.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 512.28 87.57 999999999 456.3 555.75 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9515607_1 CDM 361 RC 12032 HCPCS outpatient 585 438.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 497.66 85.07 999999999 456.3 555.75 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9515607_1 CDM 361 RC 12032 HCPCS outpatient 585 438.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 497.66 85.07 999999999 456.3 555.75 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9515607_1 CDM 361 RC 12032 HCPCS outpatient 585 438.75 MOLINA MCAID MOLINA MCAID 487.89 83.4 999999999 456.3 555.75 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9515607_1 CDM 361 RC 12032 HCPCS outpatient 585 438.75 MOLINA MCR ADV MOLINA MCR ADV 520.65 89 999999999 456.3 555.75 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9515607_1 CDM 361 RC 12032 HCPCS outpatient 585 438.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 520.65 89 999999999 456.3 555.75 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9515607_1 CDM 361 RC 12032 HCPCS outpatient 585 438.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 520.65 89 999999999 456.3 555.75 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9515607_1 CDM 361 RC 12032 HCPCS outpatient 585 438.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 526.5 90 999999999 456.3 555.75 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9515607_1 CDM 361 RC 12032 HCPCS outpatient 585 438.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 555.75 95 999999999 456.3 555.75 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9515607_1 CDM 361 RC 12032 HCPCS outpatient 585 438.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 555.75 95 999999999 456.3 555.75 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9515607_1 CDM 361 RC 12032 HCPCS outpatient 585 438.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 520.65 89 999999999 456.3 555.75 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9515607_1 CDM 361 RC 12032 HCPCS outpatient 585 438.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 514.8 88 999999999 456.3 555.75 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9515607_1 CDM 361 RC 12032 HCPCS outpatient 585 438.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 520.65 89 999999999 456.3 555.75 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9515607_2 CDM 361 RC 12032 HCPCS outpatient 585 438.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 526.5 999999999 456.3 555.75 case rate "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9515607_2 CDM 361 RC 12032 HCPCS outpatient 585 438.75 AETNA MCR ADV AETNA MCR ADV 456.3 78 999999999 456.3 555.75 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9515607_2 CDM 361 RC 12032 HCPCS outpatient 585 438.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 512.28 87.57 999999999 456.3 555.75 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9515607_2 CDM 361 RC 12032 HCPCS outpatient 585 438.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 497.66 85.07 999999999 456.3 555.75 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9515607_2 CDM 361 RC 12032 HCPCS outpatient 585 438.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 497.66 85.07 999999999 456.3 555.75 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9515607_2 CDM 361 RC 12032 HCPCS outpatient 585 438.75 MOLINA MCAID MOLINA MCAID 487.89 83.4 999999999 456.3 555.75 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9515607_2 CDM 361 RC 12032 HCPCS outpatient 585 438.75 MOLINA MCR ADV MOLINA MCR ADV 520.65 89 999999999 456.3 555.75 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9515607_2 CDM 361 RC 12032 HCPCS outpatient 585 438.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 520.65 89 999999999 456.3 555.75 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9515607_2 CDM 361 RC 12032 HCPCS outpatient 585 438.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 520.65 89 999999999 456.3 555.75 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9515607_2 CDM 361 RC 12032 HCPCS outpatient 585 438.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 526.5 90 999999999 456.3 555.75 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9515607_2 CDM 361 RC 12032 HCPCS outpatient 585 438.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 555.75 95 999999999 456.3 555.75 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9515607_2 CDM 361 RC 12032 HCPCS outpatient 585 438.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 555.75 95 999999999 456.3 555.75 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9515607_2 CDM 361 RC 12032 HCPCS outpatient 585 438.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 520.65 89 999999999 456.3 555.75 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9515607_2 CDM 361 RC 12032 HCPCS outpatient 585 438.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 514.8 88 999999999 456.3 555.75 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9515607_2 CDM 361 RC 12032 HCPCS outpatient 585 438.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 520.65 89 999999999 456.3 555.75 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, ENTIRE THORACIC AND LUMBAR, INCLUDING SKULL, CERVICAL AND SACRAL SPINE IF PERFORMED (EG, SCOLIOSIS EVALUATION); ONE VIEW" 9515634_1 CDM 320 RC 72081 HCPCS outpatient 137 102.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 123.3 90 999999999 106.86 130.15 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, ENTIRE THORACIC AND LUMBAR, INCLUDING SKULL, CERVICAL AND SACRAL SPINE IF PERFORMED (EG, SCOLIOSIS EVALUATION); ONE VIEW" 9515634_1 CDM 320 RC 72081 HCPCS outpatient 137 102.75 AETNA MCR ADV AETNA MCR ADV 106.86 78 999999999 106.86 130.15 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, ENTIRE THORACIC AND LUMBAR, INCLUDING SKULL, CERVICAL AND SACRAL SPINE IF PERFORMED (EG, SCOLIOSIS EVALUATION); ONE VIEW" 9515634_1 CDM 320 RC 72081 HCPCS outpatient 137 102.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 119.97 87.57 999999999 106.86 130.15 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, ENTIRE THORACIC AND LUMBAR, INCLUDING SKULL, CERVICAL AND SACRAL SPINE IF PERFORMED (EG, SCOLIOSIS EVALUATION); ONE VIEW" 9515634_1 CDM 320 RC 72081 HCPCS outpatient 137 102.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 116.55 85.07 999999999 106.86 130.15 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, ENTIRE THORACIC AND LUMBAR, INCLUDING SKULL, CERVICAL AND SACRAL SPINE IF PERFORMED (EG, SCOLIOSIS EVALUATION); ONE VIEW" 9515634_1 CDM 320 RC 72081 HCPCS outpatient 137 102.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 116.55 85.07 999999999 106.86 130.15 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, ENTIRE THORACIC AND LUMBAR, INCLUDING SKULL, CERVICAL AND SACRAL SPINE IF PERFORMED (EG, SCOLIOSIS EVALUATION); ONE VIEW" 9515634_1 CDM 320 RC 72081 HCPCS outpatient 137 102.75 MOLINA MCAID MOLINA MCAID 114.26 83.4 999999999 106.86 130.15 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, ENTIRE THORACIC AND LUMBAR, INCLUDING SKULL, CERVICAL AND SACRAL SPINE IF PERFORMED (EG, SCOLIOSIS EVALUATION); ONE VIEW" 9515634_1 CDM 320 RC 72081 HCPCS outpatient 137 102.75 MOLINA MCR ADV MOLINA MCR ADV 121.93 89 999999999 106.86 130.15 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, ENTIRE THORACIC AND LUMBAR, INCLUDING SKULL, CERVICAL AND SACRAL SPINE IF PERFORMED (EG, SCOLIOSIS EVALUATION); ONE VIEW" 9515634_1 CDM 320 RC 72081 HCPCS outpatient 137 102.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 121.93 89 999999999 106.86 130.15 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, ENTIRE THORACIC AND LUMBAR, INCLUDING SKULL, CERVICAL AND SACRAL SPINE IF PERFORMED (EG, SCOLIOSIS EVALUATION); ONE VIEW" 9515634_1 CDM 320 RC 72081 HCPCS outpatient 137 102.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 121.93 89 999999999 106.86 130.15 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, ENTIRE THORACIC AND LUMBAR, INCLUDING SKULL, CERVICAL AND SACRAL SPINE IF PERFORMED (EG, SCOLIOSIS EVALUATION); ONE VIEW" 9515634_1 CDM 320 RC 72081 HCPCS outpatient 137 102.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 123.3 90 999999999 106.86 130.15 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, ENTIRE THORACIC AND LUMBAR, INCLUDING SKULL, CERVICAL AND SACRAL SPINE IF PERFORMED (EG, SCOLIOSIS EVALUATION); ONE VIEW" 9515634_1 CDM 320 RC 72081 HCPCS outpatient 137 102.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 130.15 95 999999999 106.86 130.15 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, ENTIRE THORACIC AND LUMBAR, INCLUDING SKULL, CERVICAL AND SACRAL SPINE IF PERFORMED (EG, SCOLIOSIS EVALUATION); ONE VIEW" 9515634_1 CDM 320 RC 72081 HCPCS outpatient 137 102.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 130.15 95 999999999 106.86 130.15 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, ENTIRE THORACIC AND LUMBAR, INCLUDING SKULL, CERVICAL AND SACRAL SPINE IF PERFORMED (EG, SCOLIOSIS EVALUATION); ONE VIEW" 9515634_1 CDM 320 RC 72081 HCPCS outpatient 137 102.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 121.93 89 999999999 106.86 130.15 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, ENTIRE THORACIC AND LUMBAR, INCLUDING SKULL, CERVICAL AND SACRAL SPINE IF PERFORMED (EG, SCOLIOSIS EVALUATION); ONE VIEW" 9515634_1 CDM 320 RC 72081 HCPCS outpatient 137 102.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 120.56 88 999999999 106.86 130.15 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, ENTIRE THORACIC AND LUMBAR, INCLUDING SKULL, CERVICAL AND SACRAL SPINE IF PERFORMED (EG, SCOLIOSIS EVALUATION); ONE VIEW" 9515634_1 CDM 320 RC 72081 HCPCS outpatient 137 102.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 121.93 89 999999999 106.86 130.15 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, ENTIRE THORACIC AND LUMBAR, INCLUDING SKULL, CERVICAL AND SACRAL SPINE IF PERFORMED (EG, SCOLIOSIS EVALUATION); 2 OR 3 VIEWS" 9515635_1 CDM 320 RC 72082 HCPCS outpatient 384 288 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 345.6 90 999999999 299.52 364.8 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, ENTIRE THORACIC AND LUMBAR, INCLUDING SKULL, CERVICAL AND SACRAL SPINE IF PERFORMED (EG, SCOLIOSIS EVALUATION); 2 OR 3 VIEWS" 9515635_1 CDM 320 RC 72082 HCPCS outpatient 384 288 AETNA MCR ADV AETNA MCR ADV 299.52 78 999999999 299.52 364.8 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, ENTIRE THORACIC AND LUMBAR, INCLUDING SKULL, CERVICAL AND SACRAL SPINE IF PERFORMED (EG, SCOLIOSIS EVALUATION); 2 OR 3 VIEWS" 9515635_1 CDM 320 RC 72082 HCPCS outpatient 384 288 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 336.27 87.57 999999999 299.52 364.8 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, ENTIRE THORACIC AND LUMBAR, INCLUDING SKULL, CERVICAL AND SACRAL SPINE IF PERFORMED (EG, SCOLIOSIS EVALUATION); 2 OR 3 VIEWS" 9515635_1 CDM 320 RC 72082 HCPCS outpatient 384 288 COORDINATED CARE MCAID COORDINATED CARE MCAID 326.67 85.07 999999999 299.52 364.8 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, ENTIRE THORACIC AND LUMBAR, INCLUDING SKULL, CERVICAL AND SACRAL SPINE IF PERFORMED (EG, SCOLIOSIS EVALUATION); 2 OR 3 VIEWS" 9515635_1 CDM 320 RC 72082 HCPCS outpatient 384 288 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 326.67 85.07 999999999 299.52 364.8 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, ENTIRE THORACIC AND LUMBAR, INCLUDING SKULL, CERVICAL AND SACRAL SPINE IF PERFORMED (EG, SCOLIOSIS EVALUATION); 2 OR 3 VIEWS" 9515635_1 CDM 320 RC 72082 HCPCS outpatient 384 288 MOLINA MCAID MOLINA MCAID 320.26 83.4 999999999 299.52 364.8 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, ENTIRE THORACIC AND LUMBAR, INCLUDING SKULL, CERVICAL AND SACRAL SPINE IF PERFORMED (EG, SCOLIOSIS EVALUATION); 2 OR 3 VIEWS" 9515635_1 CDM 320 RC 72082 HCPCS outpatient 384 288 MOLINA MCR ADV MOLINA MCR ADV 341.76 89 999999999 299.52 364.8 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, ENTIRE THORACIC AND LUMBAR, INCLUDING SKULL, CERVICAL AND SACRAL SPINE IF PERFORMED (EG, SCOLIOSIS EVALUATION); 2 OR 3 VIEWS" 9515635_1 CDM 320 RC 72082 HCPCS outpatient 384 288 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 341.76 89 999999999 299.52 364.8 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, ENTIRE THORACIC AND LUMBAR, INCLUDING SKULL, CERVICAL AND SACRAL SPINE IF PERFORMED (EG, SCOLIOSIS EVALUATION); 2 OR 3 VIEWS" 9515635_1 CDM 320 RC 72082 HCPCS outpatient 384 288 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 341.76 89 999999999 299.52 364.8 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, ENTIRE THORACIC AND LUMBAR, INCLUDING SKULL, CERVICAL AND SACRAL SPINE IF PERFORMED (EG, SCOLIOSIS EVALUATION); 2 OR 3 VIEWS" 9515635_1 CDM 320 RC 72082 HCPCS outpatient 384 288 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 345.6 90 999999999 299.52 364.8 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, ENTIRE THORACIC AND LUMBAR, INCLUDING SKULL, CERVICAL AND SACRAL SPINE IF PERFORMED (EG, SCOLIOSIS EVALUATION); 2 OR 3 VIEWS" 9515635_1 CDM 320 RC 72082 HCPCS outpatient 384 288 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 364.8 95 999999999 299.52 364.8 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, ENTIRE THORACIC AND LUMBAR, INCLUDING SKULL, CERVICAL AND SACRAL SPINE IF PERFORMED (EG, SCOLIOSIS EVALUATION); 2 OR 3 VIEWS" 9515635_1 CDM 320 RC 72082 HCPCS outpatient 384 288 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 364.8 95 999999999 299.52 364.8 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, ENTIRE THORACIC AND LUMBAR, INCLUDING SKULL, CERVICAL AND SACRAL SPINE IF PERFORMED (EG, SCOLIOSIS EVALUATION); 2 OR 3 VIEWS" 9515635_1 CDM 320 RC 72082 HCPCS outpatient 384 288 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 341.76 89 999999999 299.52 364.8 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, ENTIRE THORACIC AND LUMBAR, INCLUDING SKULL, CERVICAL AND SACRAL SPINE IF PERFORMED (EG, SCOLIOSIS EVALUATION); 2 OR 3 VIEWS" 9515635_1 CDM 320 RC 72082 HCPCS outpatient 384 288 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 337.92 88 999999999 299.52 364.8 percent of total billed charges "RADIOLOGIC EXAMINATION, SPINE, ENTIRE THORACIC AND LUMBAR, INCLUDING SKULL, CERVICAL AND SACRAL SPINE IF PERFORMED (EG, SCOLIOSIS EVALUATION); 2 OR 3 VIEWS" 9515635_1 CDM 320 RC 72082 HCPCS outpatient 384 288 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 341.76 89 999999999 299.52 364.8 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; 1 VIEW" 9515636_1 CDM 320 RC 73501 HCPCS outpatient 175 131.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 157.5 90 999999999 136.5 166.25 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; 1 VIEW" 9515636_1 CDM 320 RC 73501 HCPCS outpatient 175 131.25 AETNA MCR ADV AETNA MCR ADV 136.5 78 999999999 136.5 166.25 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; 1 VIEW" 9515636_1 CDM 320 RC 73501 HCPCS outpatient 175 131.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 153.25 87.57 999999999 136.5 166.25 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; 1 VIEW" 9515636_1 CDM 320 RC 73501 HCPCS outpatient 175 131.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 148.87 85.07 999999999 136.5 166.25 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; 1 VIEW" 9515636_1 CDM 320 RC 73501 HCPCS outpatient 175 131.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 148.87 85.07 999999999 136.5 166.25 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; 1 VIEW" 9515636_1 CDM 320 RC 73501 HCPCS outpatient 175 131.25 MOLINA MCAID MOLINA MCAID 145.95 83.4 999999999 136.5 166.25 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; 1 VIEW" 9515636_1 CDM 320 RC 73501 HCPCS outpatient 175 131.25 MOLINA MCR ADV MOLINA MCR ADV 155.75 89 999999999 136.5 166.25 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; 1 VIEW" 9515636_1 CDM 320 RC 73501 HCPCS outpatient 175 131.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 155.75 89 999999999 136.5 166.25 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; 1 VIEW" 9515636_1 CDM 320 RC 73501 HCPCS outpatient 175 131.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 155.75 89 999999999 136.5 166.25 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; 1 VIEW" 9515636_1 CDM 320 RC 73501 HCPCS outpatient 175 131.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 157.5 90 999999999 136.5 166.25 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; 1 VIEW" 9515636_1 CDM 320 RC 73501 HCPCS outpatient 175 131.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 166.25 95 999999999 136.5 166.25 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; 1 VIEW" 9515636_1 CDM 320 RC 73501 HCPCS outpatient 175 131.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 166.25 95 999999999 136.5 166.25 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; 1 VIEW" 9515636_1 CDM 320 RC 73501 HCPCS outpatient 175 131.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 155.75 89 999999999 136.5 166.25 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; 1 VIEW" 9515636_1 CDM 320 RC 73501 HCPCS outpatient 175 131.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 154 88 999999999 136.5 166.25 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; 1 VIEW" 9515636_1 CDM 320 RC 73501 HCPCS outpatient 175 131.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 155.75 89 999999999 136.5 166.25 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; 2-3 VIEWS" 9515637_1 CDM 320 RC 73502 HCPCS outpatient 279 209.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 251.1 90 999999999 217.62 265.05 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; 2-3 VIEWS" 9515637_1 CDM 320 RC 73502 HCPCS outpatient 279 209.25 AETNA MCR ADV AETNA MCR ADV 217.62 78 999999999 217.62 265.05 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; 2-3 VIEWS" 9515637_1 CDM 320 RC 73502 HCPCS outpatient 279 209.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 244.32 87.57 999999999 217.62 265.05 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; 2-3 VIEWS" 9515637_1 CDM 320 RC 73502 HCPCS outpatient 279 209.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 237.35 85.07 999999999 217.62 265.05 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; 2-3 VIEWS" 9515637_1 CDM 320 RC 73502 HCPCS outpatient 279 209.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 237.35 85.07 999999999 217.62 265.05 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; 2-3 VIEWS" 9515637_1 CDM 320 RC 73502 HCPCS outpatient 279 209.25 MOLINA MCAID MOLINA MCAID 232.69 83.4 999999999 217.62 265.05 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; 2-3 VIEWS" 9515637_1 CDM 320 RC 73502 HCPCS outpatient 279 209.25 MOLINA MCR ADV MOLINA MCR ADV 248.31 89 999999999 217.62 265.05 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; 2-3 VIEWS" 9515637_1 CDM 320 RC 73502 HCPCS outpatient 279 209.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 248.31 89 999999999 217.62 265.05 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; 2-3 VIEWS" 9515637_1 CDM 320 RC 73502 HCPCS outpatient 279 209.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 248.31 89 999999999 217.62 265.05 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; 2-3 VIEWS" 9515637_1 CDM 320 RC 73502 HCPCS outpatient 279 209.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 251.1 90 999999999 217.62 265.05 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; 2-3 VIEWS" 9515637_1 CDM 320 RC 73502 HCPCS outpatient 279 209.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 265.05 95 999999999 217.62 265.05 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; 2-3 VIEWS" 9515637_1 CDM 320 RC 73502 HCPCS outpatient 279 209.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 265.05 95 999999999 217.62 265.05 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; 2-3 VIEWS" 9515637_1 CDM 320 RC 73502 HCPCS outpatient 279 209.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 248.31 89 999999999 217.62 265.05 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; 2-3 VIEWS" 9515637_1 CDM 320 RC 73502 HCPCS outpatient 279 209.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 245.52 88 999999999 217.62 265.05 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; 2-3 VIEWS" 9515637_1 CDM 320 RC 73502 HCPCS outpatient 279 209.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 248.31 89 999999999 217.62 265.05 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; MINIMUM OF 4 VIEWS" 9515638_1 CDM 320 RC 73503 HCPCS outpatient 402 301.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 361.8 90 999999999 313.56 381.9 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; MINIMUM OF 4 VIEWS" 9515638_1 CDM 320 RC 73503 HCPCS outpatient 402 301.5 AETNA MCR ADV AETNA MCR ADV 313.56 78 999999999 313.56 381.9 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; MINIMUM OF 4 VIEWS" 9515638_1 CDM 320 RC 73503 HCPCS outpatient 402 301.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 352.03 87.57 999999999 313.56 381.9 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; MINIMUM OF 4 VIEWS" 9515638_1 CDM 320 RC 73503 HCPCS outpatient 402 301.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 341.98 85.07 999999999 313.56 381.9 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; MINIMUM OF 4 VIEWS" 9515638_1 CDM 320 RC 73503 HCPCS outpatient 402 301.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 341.98 85.07 999999999 313.56 381.9 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; MINIMUM OF 4 VIEWS" 9515638_1 CDM 320 RC 73503 HCPCS outpatient 402 301.5 MOLINA MCAID MOLINA MCAID 335.27 83.4 999999999 313.56 381.9 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; MINIMUM OF 4 VIEWS" 9515638_1 CDM 320 RC 73503 HCPCS outpatient 402 301.5 MOLINA MCR ADV MOLINA MCR ADV 357.78 89 999999999 313.56 381.9 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; MINIMUM OF 4 VIEWS" 9515638_1 CDM 320 RC 73503 HCPCS outpatient 402 301.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 357.78 89 999999999 313.56 381.9 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; MINIMUM OF 4 VIEWS" 9515638_1 CDM 320 RC 73503 HCPCS outpatient 402 301.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 357.78 89 999999999 313.56 381.9 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; MINIMUM OF 4 VIEWS" 9515638_1 CDM 320 RC 73503 HCPCS outpatient 402 301.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 361.8 90 999999999 313.56 381.9 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; MINIMUM OF 4 VIEWS" 9515638_1 CDM 320 RC 73503 HCPCS outpatient 402 301.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 381.9 95 999999999 313.56 381.9 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; MINIMUM OF 4 VIEWS" 9515638_1 CDM 320 RC 73503 HCPCS outpatient 402 301.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 381.9 95 999999999 313.56 381.9 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; MINIMUM OF 4 VIEWS" 9515638_1 CDM 320 RC 73503 HCPCS outpatient 402 301.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 357.78 89 999999999 313.56 381.9 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; MINIMUM OF 4 VIEWS" 9515638_1 CDM 320 RC 73503 HCPCS outpatient 402 301.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 353.76 88 999999999 313.56 381.9 percent of total billed charges "RADIOLOGIC EXAMINATION, HIP, UNILATERAL, WITH PELVIS WHEN PERFORMED; MINIMUM OF 4 VIEWS" 9515638_1 CDM 320 RC 73503 HCPCS outpatient 402 301.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 357.78 89 999999999 313.56 381.9 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; 2 VIEWS" 9515639_1 CDM 320 RC 73521 HCPCS outpatient 217 162.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 195.3 90 999999999 169.26 206.15 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; 2 VIEWS" 9515639_1 CDM 320 RC 73521 HCPCS outpatient 217 162.75 AETNA MCR ADV AETNA MCR ADV 169.26 78 999999999 169.26 206.15 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; 2 VIEWS" 9515639_1 CDM 320 RC 73521 HCPCS outpatient 217 162.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 190.03 87.57 999999999 169.26 206.15 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; 2 VIEWS" 9515639_1 CDM 320 RC 73521 HCPCS outpatient 217 162.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 184.6 85.07 999999999 169.26 206.15 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; 2 VIEWS" 9515639_1 CDM 320 RC 73521 HCPCS outpatient 217 162.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 184.6 85.07 999999999 169.26 206.15 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; 2 VIEWS" 9515639_1 CDM 320 RC 73521 HCPCS outpatient 217 162.75 MOLINA MCAID MOLINA MCAID 180.98 83.4 999999999 169.26 206.15 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; 2 VIEWS" 9515639_1 CDM 320 RC 73521 HCPCS outpatient 217 162.75 MOLINA MCR ADV MOLINA MCR ADV 193.13 89 999999999 169.26 206.15 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; 2 VIEWS" 9515639_1 CDM 320 RC 73521 HCPCS outpatient 217 162.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 193.13 89 999999999 169.26 206.15 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; 2 VIEWS" 9515639_1 CDM 320 RC 73521 HCPCS outpatient 217 162.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 193.13 89 999999999 169.26 206.15 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; 2 VIEWS" 9515639_1 CDM 320 RC 73521 HCPCS outpatient 217 162.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 195.3 90 999999999 169.26 206.15 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; 2 VIEWS" 9515639_1 CDM 320 RC 73521 HCPCS outpatient 217 162.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 206.15 95 999999999 169.26 206.15 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; 2 VIEWS" 9515639_1 CDM 320 RC 73521 HCPCS outpatient 217 162.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 206.15 95 999999999 169.26 206.15 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; 2 VIEWS" 9515639_1 CDM 320 RC 73521 HCPCS outpatient 217 162.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 193.13 89 999999999 169.26 206.15 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; 2 VIEWS" 9515639_1 CDM 320 RC 73521 HCPCS outpatient 217 162.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 190.96 88 999999999 169.26 206.15 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; 2 VIEWS" 9515639_1 CDM 320 RC 73521 HCPCS outpatient 217 162.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 193.13 89 999999999 169.26 206.15 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; 3-4 VIEWS" 9515640_1 CDM 320 RC 73522 HCPCS outpatient 316 237 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 284.4 90 999999999 246.48 300.2 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; 3-4 VIEWS" 9515640_1 CDM 320 RC 73522 HCPCS outpatient 316 237 AETNA MCR ADV AETNA MCR ADV 246.48 78 999999999 246.48 300.2 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; 3-4 VIEWS" 9515640_1 CDM 320 RC 73522 HCPCS outpatient 316 237 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 276.72 87.57 999999999 246.48 300.2 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; 3-4 VIEWS" 9515640_1 CDM 320 RC 73522 HCPCS outpatient 316 237 COORDINATED CARE MCAID COORDINATED CARE MCAID 268.82 85.07 999999999 246.48 300.2 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; 3-4 VIEWS" 9515640_1 CDM 320 RC 73522 HCPCS outpatient 316 237 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 268.82 85.07 999999999 246.48 300.2 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; 3-4 VIEWS" 9515640_1 CDM 320 RC 73522 HCPCS outpatient 316 237 MOLINA MCAID MOLINA MCAID 263.54 83.4 999999999 246.48 300.2 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; 3-4 VIEWS" 9515640_1 CDM 320 RC 73522 HCPCS outpatient 316 237 MOLINA MCR ADV MOLINA MCR ADV 281.24 89 999999999 246.48 300.2 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; 3-4 VIEWS" 9515640_1 CDM 320 RC 73522 HCPCS outpatient 316 237 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 281.24 89 999999999 246.48 300.2 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; 3-4 VIEWS" 9515640_1 CDM 320 RC 73522 HCPCS outpatient 316 237 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 281.24 89 999999999 246.48 300.2 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; 3-4 VIEWS" 9515640_1 CDM 320 RC 73522 HCPCS outpatient 316 237 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 284.4 90 999999999 246.48 300.2 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; 3-4 VIEWS" 9515640_1 CDM 320 RC 73522 HCPCS outpatient 316 237 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 300.2 95 999999999 246.48 300.2 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; 3-4 VIEWS" 9515640_1 CDM 320 RC 73522 HCPCS outpatient 316 237 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 300.2 95 999999999 246.48 300.2 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; 3-4 VIEWS" 9515640_1 CDM 320 RC 73522 HCPCS outpatient 316 237 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 281.24 89 999999999 246.48 300.2 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; 3-4 VIEWS" 9515640_1 CDM 320 RC 73522 HCPCS outpatient 316 237 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 278.08 88 999999999 246.48 300.2 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; 3-4 VIEWS" 9515640_1 CDM 320 RC 73522 HCPCS outpatient 316 237 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 281.24 89 999999999 246.48 300.2 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; MINIMUM OF 5 VIEWS" 9515641_1 CDM 320 RC 73523 HCPCS outpatient 481 360.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 432.9 90 999999999 375.18 456.95 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; MINIMUM OF 5 VIEWS" 9515641_1 CDM 320 RC 73523 HCPCS outpatient 481 360.75 AETNA MCR ADV AETNA MCR ADV 375.18 78 999999999 375.18 456.95 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; MINIMUM OF 5 VIEWS" 9515641_1 CDM 320 RC 73523 HCPCS outpatient 481 360.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 421.21 87.57 999999999 375.18 456.95 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; MINIMUM OF 5 VIEWS" 9515641_1 CDM 320 RC 73523 HCPCS outpatient 481 360.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 409.19 85.07 999999999 375.18 456.95 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; MINIMUM OF 5 VIEWS" 9515641_1 CDM 320 RC 73523 HCPCS outpatient 481 360.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 409.19 85.07 999999999 375.18 456.95 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; MINIMUM OF 5 VIEWS" 9515641_1 CDM 320 RC 73523 HCPCS outpatient 481 360.75 MOLINA MCAID MOLINA MCAID 401.15 83.4 999999999 375.18 456.95 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; MINIMUM OF 5 VIEWS" 9515641_1 CDM 320 RC 73523 HCPCS outpatient 481 360.75 MOLINA MCR ADV MOLINA MCR ADV 428.09 89 999999999 375.18 456.95 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; MINIMUM OF 5 VIEWS" 9515641_1 CDM 320 RC 73523 HCPCS outpatient 481 360.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 428.09 89 999999999 375.18 456.95 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; MINIMUM OF 5 VIEWS" 9515641_1 CDM 320 RC 73523 HCPCS outpatient 481 360.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 428.09 89 999999999 375.18 456.95 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; MINIMUM OF 5 VIEWS" 9515641_1 CDM 320 RC 73523 HCPCS outpatient 481 360.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 432.9 90 999999999 375.18 456.95 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; MINIMUM OF 5 VIEWS" 9515641_1 CDM 320 RC 73523 HCPCS outpatient 481 360.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 456.95 95 999999999 375.18 456.95 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; MINIMUM OF 5 VIEWS" 9515641_1 CDM 320 RC 73523 HCPCS outpatient 481 360.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 456.95 95 999999999 375.18 456.95 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; MINIMUM OF 5 VIEWS" 9515641_1 CDM 320 RC 73523 HCPCS outpatient 481 360.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 428.09 89 999999999 375.18 456.95 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; MINIMUM OF 5 VIEWS" 9515641_1 CDM 320 RC 73523 HCPCS outpatient 481 360.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 423.28 88 999999999 375.18 456.95 percent of total billed charges "RADIOLOGIC EXAMINATION, HIPS, BILATERAL, WITH PELVIS WHEN PERFORMED; MINIMUM OF 5 VIEWS" 9515641_1 CDM 320 RC 73523 HCPCS outpatient 481 360.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 428.09 89 999999999 375.18 456.95 percent of total billed charges "RADIOLOGIC EXAMINATION, FEMUR; MINIMUM 2 VIEWS" 9515642_1 CDM 320 RC 73552 HCPCS outpatient 308 231 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 277.2 90 999999999 240.24 292.6 percent of total billed charges "RADIOLOGIC EXAMINATION, FEMUR; MINIMUM 2 VIEWS" 9515642_1 CDM 320 RC 73552 HCPCS outpatient 308 231 AETNA MCR ADV AETNA MCR ADV 240.24 78 999999999 240.24 292.6 percent of total billed charges "RADIOLOGIC EXAMINATION, FEMUR; MINIMUM 2 VIEWS" 9515642_1 CDM 320 RC 73552 HCPCS outpatient 308 231 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 269.72 87.57 999999999 240.24 292.6 percent of total billed charges "RADIOLOGIC EXAMINATION, FEMUR; MINIMUM 2 VIEWS" 9515642_1 CDM 320 RC 73552 HCPCS outpatient 308 231 COORDINATED CARE MCAID COORDINATED CARE MCAID 262.02 85.07 999999999 240.24 292.6 percent of total billed charges "RADIOLOGIC EXAMINATION, FEMUR; MINIMUM 2 VIEWS" 9515642_1 CDM 320 RC 73552 HCPCS outpatient 308 231 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 262.02 85.07 999999999 240.24 292.6 percent of total billed charges "RADIOLOGIC EXAMINATION, FEMUR; MINIMUM 2 VIEWS" 9515642_1 CDM 320 RC 73552 HCPCS outpatient 308 231 MOLINA MCAID MOLINA MCAID 256.87 83.4 999999999 240.24 292.6 percent of total billed charges "RADIOLOGIC EXAMINATION, FEMUR; MINIMUM 2 VIEWS" 9515642_1 CDM 320 RC 73552 HCPCS outpatient 308 231 MOLINA MCR ADV MOLINA MCR ADV 274.12 89 999999999 240.24 292.6 percent of total billed charges "RADIOLOGIC EXAMINATION, FEMUR; MINIMUM 2 VIEWS" 9515642_1 CDM 320 RC 73552 HCPCS outpatient 308 231 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 274.12 89 999999999 240.24 292.6 percent of total billed charges "RADIOLOGIC EXAMINATION, FEMUR; MINIMUM 2 VIEWS" 9515642_1 CDM 320 RC 73552 HCPCS outpatient 308 231 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 274.12 89 999999999 240.24 292.6 percent of total billed charges "RADIOLOGIC EXAMINATION, FEMUR; MINIMUM 2 VIEWS" 9515642_1 CDM 320 RC 73552 HCPCS outpatient 308 231 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 277.2 90 999999999 240.24 292.6 percent of total billed charges "RADIOLOGIC EXAMINATION, FEMUR; MINIMUM 2 VIEWS" 9515642_1 CDM 320 RC 73552 HCPCS outpatient 308 231 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 292.6 95 999999999 240.24 292.6 percent of total billed charges "RADIOLOGIC EXAMINATION, FEMUR; MINIMUM 2 VIEWS" 9515642_1 CDM 320 RC 73552 HCPCS outpatient 308 231 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 292.6 95 999999999 240.24 292.6 percent of total billed charges "RADIOLOGIC EXAMINATION, FEMUR; MINIMUM 2 VIEWS" 9515642_1 CDM 320 RC 73552 HCPCS outpatient 308 231 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 274.12 89 999999999 240.24 292.6 percent of total billed charges "RADIOLOGIC EXAMINATION, FEMUR; MINIMUM 2 VIEWS" 9515642_1 CDM 320 RC 73552 HCPCS outpatient 308 231 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 271.04 88 999999999 240.24 292.6 percent of total billed charges "RADIOLOGIC EXAMINATION, FEMUR; MINIMUM 2 VIEWS" 9515642_1 CDM 320 RC 73552 HCPCS outpatient 308 231 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 274.12 89 999999999 240.24 292.6 percent of total billed charges "INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 9515696_1 CDM 636 RC 90688 HCPCS outpatient 55 41.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 49.5 90 999999999 42.9 52.25 percent of total billed charges "INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 9515696_1 CDM 636 RC 90688 HCPCS outpatient 55 41.25 AETNA MCR ADV AETNA MCR ADV 42.9 78 999999999 42.9 52.25 percent of total billed charges "INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 9515696_1 CDM 636 RC 90688 HCPCS outpatient 55 41.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 48.16 87.57 999999999 42.9 52.25 percent of total billed charges "INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 9515696_1 CDM 636 RC 90688 HCPCS outpatient 55 41.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 46.79 85.07 999999999 42.9 52.25 percent of total billed charges "INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 9515696_1 CDM 636 RC 90688 HCPCS outpatient 55 41.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 46.79 85.07 999999999 42.9 52.25 percent of total billed charges "INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 9515696_1 CDM 636 RC 90688 HCPCS outpatient 55 41.25 MOLINA MCAID MOLINA MCAID 45.87 83.4 999999999 42.9 52.25 percent of total billed charges "INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 9515696_1 CDM 636 RC 90688 HCPCS outpatient 55 41.25 MOLINA MCR ADV MOLINA MCR ADV 48.95 89 999999999 42.9 52.25 percent of total billed charges "INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 9515696_1 CDM 636 RC 90688 HCPCS outpatient 55 41.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 48.95 89 999999999 42.9 52.25 percent of total billed charges "INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 9515696_1 CDM 636 RC 90688 HCPCS outpatient 55 41.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 48.95 89 999999999 42.9 52.25 percent of total billed charges "INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 9515696_1 CDM 636 RC 90688 HCPCS outpatient 55 41.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 49.5 90 999999999 42.9 52.25 percent of total billed charges "INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 9515696_1 CDM 636 RC 90688 HCPCS outpatient 55 41.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 52.25 95 999999999 42.9 52.25 percent of total billed charges "INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 9515696_1 CDM 636 RC 90688 HCPCS outpatient 55 41.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 52.25 95 999999999 42.9 52.25 percent of total billed charges "INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 9515696_1 CDM 636 RC 90688 HCPCS outpatient 55 41.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 48.95 89 999999999 42.9 52.25 percent of total billed charges "INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 9515696_1 CDM 636 RC 90688 HCPCS outpatient 55 41.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 48.4 88 999999999 42.9 52.25 percent of total billed charges "INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT VIRUS, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE" 9515696_1 CDM 636 RC 90688 HCPCS outpatient 55 41.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 48.95 89 999999999 42.9 52.25 percent of total billed charges "ULTRASOUND, ABDOMINAL AORTA, REAL TIME WITH IMAGE DOCUMENTATION, SCREENING STUDY FOR ABDOMINAL AORTIC ANEURYSM (AAA)" 9515803_1 CDM 402 RC 76706 HCPCS outpatient 676 507 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 608.4 90 999999999 527.28 642.2 percent of total billed charges "ULTRASOUND, ABDOMINAL AORTA, REAL TIME WITH IMAGE DOCUMENTATION, SCREENING STUDY FOR ABDOMINAL AORTIC ANEURYSM (AAA)" 9515803_1 CDM 402 RC 76706 HCPCS outpatient 676 507 AETNA MCR ADV AETNA MCR ADV 527.28 78 999999999 527.28 642.2 percent of total billed charges "ULTRASOUND, ABDOMINAL AORTA, REAL TIME WITH IMAGE DOCUMENTATION, SCREENING STUDY FOR ABDOMINAL AORTIC ANEURYSM (AAA)" 9515803_1 CDM 402 RC 76706 HCPCS outpatient 676 507 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 591.97 87.57 999999999 527.28 642.2 percent of total billed charges "ULTRASOUND, ABDOMINAL AORTA, REAL TIME WITH IMAGE DOCUMENTATION, SCREENING STUDY FOR ABDOMINAL AORTIC ANEURYSM (AAA)" 9515803_1 CDM 402 RC 76706 HCPCS outpatient 676 507 COORDINATED CARE MCAID COORDINATED CARE MCAID 575.07 85.07 999999999 527.28 642.2 percent of total billed charges "ULTRASOUND, ABDOMINAL AORTA, REAL TIME WITH IMAGE DOCUMENTATION, SCREENING STUDY FOR ABDOMINAL AORTIC ANEURYSM (AAA)" 9515803_1 CDM 402 RC 76706 HCPCS outpatient 676 507 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 575.07 85.07 999999999 527.28 642.2 percent of total billed charges "ULTRASOUND, ABDOMINAL AORTA, REAL TIME WITH IMAGE DOCUMENTATION, SCREENING STUDY FOR ABDOMINAL AORTIC ANEURYSM (AAA)" 9515803_1 CDM 402 RC 76706 HCPCS outpatient 676 507 MOLINA MCAID MOLINA MCAID 563.78 83.4 999999999 527.28 642.2 percent of total billed charges "ULTRASOUND, ABDOMINAL AORTA, REAL TIME WITH IMAGE DOCUMENTATION, SCREENING STUDY FOR ABDOMINAL AORTIC ANEURYSM (AAA)" 9515803_1 CDM 402 RC 76706 HCPCS outpatient 676 507 MOLINA MCR ADV MOLINA MCR ADV 601.64 89 999999999 527.28 642.2 percent of total billed charges "ULTRASOUND, ABDOMINAL AORTA, REAL TIME WITH IMAGE DOCUMENTATION, SCREENING STUDY FOR ABDOMINAL AORTIC ANEURYSM (AAA)" 9515803_1 CDM 402 RC 76706 HCPCS outpatient 676 507 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 601.64 89 999999999 527.28 642.2 percent of total billed charges "ULTRASOUND, ABDOMINAL AORTA, REAL TIME WITH IMAGE DOCUMENTATION, SCREENING STUDY FOR ABDOMINAL AORTIC ANEURYSM (AAA)" 9515803_1 CDM 402 RC 76706 HCPCS outpatient 676 507 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 601.64 89 999999999 527.28 642.2 percent of total billed charges "ULTRASOUND, ABDOMINAL AORTA, REAL TIME WITH IMAGE DOCUMENTATION, SCREENING STUDY FOR ABDOMINAL AORTIC ANEURYSM (AAA)" 9515803_1 CDM 402 RC 76706 HCPCS outpatient 676 507 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 608.4 90 999999999 527.28 642.2 percent of total billed charges "ULTRASOUND, ABDOMINAL AORTA, REAL TIME WITH IMAGE DOCUMENTATION, SCREENING STUDY FOR ABDOMINAL AORTIC ANEURYSM (AAA)" 9515803_1 CDM 402 RC 76706 HCPCS outpatient 676 507 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 642.2 95 999999999 527.28 642.2 percent of total billed charges "ULTRASOUND, ABDOMINAL AORTA, REAL TIME WITH IMAGE DOCUMENTATION, SCREENING STUDY FOR ABDOMINAL AORTIC ANEURYSM (AAA)" 9515803_1 CDM 402 RC 76706 HCPCS outpatient 676 507 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 642.2 95 999999999 527.28 642.2 percent of total billed charges "ULTRASOUND, ABDOMINAL AORTA, REAL TIME WITH IMAGE DOCUMENTATION, SCREENING STUDY FOR ABDOMINAL AORTIC ANEURYSM (AAA)" 9515803_1 CDM 402 RC 76706 HCPCS outpatient 676 507 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 601.64 89 999999999 527.28 642.2 percent of total billed charges "ULTRASOUND, ABDOMINAL AORTA, REAL TIME WITH IMAGE DOCUMENTATION, SCREENING STUDY FOR ABDOMINAL AORTIC ANEURYSM (AAA)" 9515803_1 CDM 402 RC 76706 HCPCS outpatient 676 507 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 594.88 88 999999999 527.28 642.2 percent of total billed charges "ULTRASOUND, ABDOMINAL AORTA, REAL TIME WITH IMAGE DOCUMENTATION, SCREENING STUDY FOR ABDOMINAL AORTIC ANEURYSM (AAA)" 9515803_1 CDM 402 RC 76706 HCPCS outpatient 676 507 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 601.64 89 999999999 527.28 642.2 percent of total billed charges "PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY WITH NO PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEM(S) USING STANDARDIZED TESTS AND MEASURES ADDRESSING 1-2 ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; A CLINICAL PRESENTATION WITH STABLE AND/OR UNCOMPLICATED CHARACTERISTICS; AND CLINICAL DECISION MAKING OF LOW COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 20 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515806_1 CDM 424 RC 97161 HCPCS outpatient 218 163.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 196.2 90 999999999 170.04 207.1 percent of total billed charges "PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY WITH NO PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEM(S) USING STANDARDIZED TESTS AND MEASURES ADDRESSING 1-2 ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; A CLINICAL PRESENTATION WITH STABLE AND/OR UNCOMPLICATED CHARACTERISTICS; AND CLINICAL DECISION MAKING OF LOW COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 20 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515806_1 CDM 424 RC 97161 HCPCS outpatient 218 163.5 AETNA MCR ADV AETNA MCR ADV 170.04 78 999999999 170.04 207.1 percent of total billed charges "PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY WITH NO PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEM(S) USING STANDARDIZED TESTS AND MEASURES ADDRESSING 1-2 ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; A CLINICAL PRESENTATION WITH STABLE AND/OR UNCOMPLICATED CHARACTERISTICS; AND CLINICAL DECISION MAKING OF LOW COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 20 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515806_1 CDM 424 RC 97161 HCPCS outpatient 218 163.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 190.9 87.57 999999999 170.04 207.1 percent of total billed charges "PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY WITH NO PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEM(S) USING STANDARDIZED TESTS AND MEASURES ADDRESSING 1-2 ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; A CLINICAL PRESENTATION WITH STABLE AND/OR UNCOMPLICATED CHARACTERISTICS; AND CLINICAL DECISION MAKING OF LOW COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 20 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515806_1 CDM 424 RC 97161 HCPCS outpatient 218 163.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 185.45 85.07 999999999 170.04 207.1 percent of total billed charges "PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY WITH NO PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEM(S) USING STANDARDIZED TESTS AND MEASURES ADDRESSING 1-2 ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; A CLINICAL PRESENTATION WITH STABLE AND/OR UNCOMPLICATED CHARACTERISTICS; AND CLINICAL DECISION MAKING OF LOW COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 20 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515806_1 CDM 424 RC 97161 HCPCS outpatient 218 163.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 185.45 85.07 999999999 170.04 207.1 percent of total billed charges "PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY WITH NO PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEM(S) USING STANDARDIZED TESTS AND MEASURES ADDRESSING 1-2 ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; A CLINICAL PRESENTATION WITH STABLE AND/OR UNCOMPLICATED CHARACTERISTICS; AND CLINICAL DECISION MAKING OF LOW COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 20 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515806_1 CDM 424 RC 97161 HCPCS outpatient 218 163.5 MOLINA MCAID MOLINA MCAID 181.81 83.4 999999999 170.04 207.1 percent of total billed charges "PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY WITH NO PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEM(S) USING STANDARDIZED TESTS AND MEASURES ADDRESSING 1-2 ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; A CLINICAL PRESENTATION WITH STABLE AND/OR UNCOMPLICATED CHARACTERISTICS; AND CLINICAL DECISION MAKING OF LOW COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 20 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515806_1 CDM 424 RC 97161 HCPCS outpatient 218 163.5 MOLINA MCR ADV MOLINA MCR ADV 194.02 89 999999999 170.04 207.1 percent of total billed charges "PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY WITH NO PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEM(S) USING STANDARDIZED TESTS AND MEASURES ADDRESSING 1-2 ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; A CLINICAL PRESENTATION WITH STABLE AND/OR UNCOMPLICATED CHARACTERISTICS; AND CLINICAL DECISION MAKING OF LOW COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 20 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515806_1 CDM 424 RC 97161 HCPCS outpatient 218 163.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 194.02 89 999999999 170.04 207.1 percent of total billed charges "PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY WITH NO PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEM(S) USING STANDARDIZED TESTS AND MEASURES ADDRESSING 1-2 ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; A CLINICAL PRESENTATION WITH STABLE AND/OR UNCOMPLICATED CHARACTERISTICS; AND CLINICAL DECISION MAKING OF LOW COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 20 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515806_1 CDM 424 RC 97161 HCPCS outpatient 218 163.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 194.02 89 999999999 170.04 207.1 percent of total billed charges "PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY WITH NO PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEM(S) USING STANDARDIZED TESTS AND MEASURES ADDRESSING 1-2 ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; A CLINICAL PRESENTATION WITH STABLE AND/OR UNCOMPLICATED CHARACTERISTICS; AND CLINICAL DECISION MAKING OF LOW COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 20 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515806_1 CDM 424 RC 97161 HCPCS outpatient 218 163.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 196.2 90 999999999 170.04 207.1 percent of total billed charges "PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY WITH NO PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEM(S) USING STANDARDIZED TESTS AND MEASURES ADDRESSING 1-2 ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; A CLINICAL PRESENTATION WITH STABLE AND/OR UNCOMPLICATED CHARACTERISTICS; AND CLINICAL DECISION MAKING OF LOW COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 20 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515806_1 CDM 424 RC 97161 HCPCS outpatient 218 163.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 207.1 95 999999999 170.04 207.1 percent of total billed charges "PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY WITH NO PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEM(S) USING STANDARDIZED TESTS AND MEASURES ADDRESSING 1-2 ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; A CLINICAL PRESENTATION WITH STABLE AND/OR UNCOMPLICATED CHARACTERISTICS; AND CLINICAL DECISION MAKING OF LOW COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 20 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515806_1 CDM 424 RC 97161 HCPCS outpatient 218 163.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 207.1 95 999999999 170.04 207.1 percent of total billed charges "PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY WITH NO PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEM(S) USING STANDARDIZED TESTS AND MEASURES ADDRESSING 1-2 ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; A CLINICAL PRESENTATION WITH STABLE AND/OR UNCOMPLICATED CHARACTERISTICS; AND CLINICAL DECISION MAKING OF LOW COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 20 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515806_1 CDM 424 RC 97161 HCPCS outpatient 218 163.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 194.02 89 999999999 170.04 207.1 percent of total billed charges "PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY WITH NO PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEM(S) USING STANDARDIZED TESTS AND MEASURES ADDRESSING 1-2 ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; A CLINICAL PRESENTATION WITH STABLE AND/OR UNCOMPLICATED CHARACTERISTICS; AND CLINICAL DECISION MAKING OF LOW COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 20 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515806_1 CDM 424 RC 97161 HCPCS outpatient 218 163.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 191.84 88 999999999 170.04 207.1 percent of total billed charges "PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY WITH NO PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEM(S) USING STANDARDIZED TESTS AND MEASURES ADDRESSING 1-2 ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; A CLINICAL PRESENTATION WITH STABLE AND/OR UNCOMPLICATED CHARACTERISTICS; AND CLINICAL DECISION MAKING OF LOW COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 20 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515806_1 CDM 424 RC 97161 HCPCS outpatient 218 163.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 194.02 89 999999999 170.04 207.1 percent of total billed charges "PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY OF PRESENT PROBLEM WITH 1-2 PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEMS USING STANDARDIZED TESTS AND MEASURES IN ADDRESSING A TOTAL OF 3 OR MORE ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; AN EVOLVING CLINICAL PRESENTATION WITH CHANGING CHARACTERISTICS; AND CLINICAL DECISION MAKING OF MODERATE COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515807_1 CDM 424 RC 97162 HCPCS outpatient 218 163.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 196.2 90 999999999 170.04 207.1 percent of total billed charges "PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY OF PRESENT PROBLEM WITH 1-2 PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEMS USING STANDARDIZED TESTS AND MEASURES IN ADDRESSING A TOTAL OF 3 OR MORE ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; AN EVOLVING CLINICAL PRESENTATION WITH CHANGING CHARACTERISTICS; AND CLINICAL DECISION MAKING OF MODERATE COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515807_1 CDM 424 RC 97162 HCPCS outpatient 218 163.5 AETNA MCR ADV AETNA MCR ADV 170.04 78 999999999 170.04 207.1 percent of total billed charges "PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY OF PRESENT PROBLEM WITH 1-2 PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEMS USING STANDARDIZED TESTS AND MEASURES IN ADDRESSING A TOTAL OF 3 OR MORE ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; AN EVOLVING CLINICAL PRESENTATION WITH CHANGING CHARACTERISTICS; AND CLINICAL DECISION MAKING OF MODERATE COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515807_1 CDM 424 RC 97162 HCPCS outpatient 218 163.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 190.9 87.57 999999999 170.04 207.1 percent of total billed charges "PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY OF PRESENT PROBLEM WITH 1-2 PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEMS USING STANDARDIZED TESTS AND MEASURES IN ADDRESSING A TOTAL OF 3 OR MORE ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; AN EVOLVING CLINICAL PRESENTATION WITH CHANGING CHARACTERISTICS; AND CLINICAL DECISION MAKING OF MODERATE COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515807_1 CDM 424 RC 97162 HCPCS outpatient 218 163.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 185.45 85.07 999999999 170.04 207.1 percent of total billed charges "PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY OF PRESENT PROBLEM WITH 1-2 PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEMS USING STANDARDIZED TESTS AND MEASURES IN ADDRESSING A TOTAL OF 3 OR MORE ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; AN EVOLVING CLINICAL PRESENTATION WITH CHANGING CHARACTERISTICS; AND CLINICAL DECISION MAKING OF MODERATE COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515807_1 CDM 424 RC 97162 HCPCS outpatient 218 163.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 185.45 85.07 999999999 170.04 207.1 percent of total billed charges "PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY OF PRESENT PROBLEM WITH 1-2 PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEMS USING STANDARDIZED TESTS AND MEASURES IN ADDRESSING A TOTAL OF 3 OR MORE ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; AN EVOLVING CLINICAL PRESENTATION WITH CHANGING CHARACTERISTICS; AND CLINICAL DECISION MAKING OF MODERATE COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515807_1 CDM 424 RC 97162 HCPCS outpatient 218 163.5 MOLINA MCAID MOLINA MCAID 181.81 83.4 999999999 170.04 207.1 percent of total billed charges "PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY OF PRESENT PROBLEM WITH 1-2 PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEMS USING STANDARDIZED TESTS AND MEASURES IN ADDRESSING A TOTAL OF 3 OR MORE ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; AN EVOLVING CLINICAL PRESENTATION WITH CHANGING CHARACTERISTICS; AND CLINICAL DECISION MAKING OF MODERATE COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515807_1 CDM 424 RC 97162 HCPCS outpatient 218 163.5 MOLINA MCR ADV MOLINA MCR ADV 194.02 89 999999999 170.04 207.1 percent of total billed charges "PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY OF PRESENT PROBLEM WITH 1-2 PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEMS USING STANDARDIZED TESTS AND MEASURES IN ADDRESSING A TOTAL OF 3 OR MORE ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; AN EVOLVING CLINICAL PRESENTATION WITH CHANGING CHARACTERISTICS; AND CLINICAL DECISION MAKING OF MODERATE COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515807_1 CDM 424 RC 97162 HCPCS outpatient 218 163.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 194.02 89 999999999 170.04 207.1 percent of total billed charges "PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY OF PRESENT PROBLEM WITH 1-2 PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEMS USING STANDARDIZED TESTS AND MEASURES IN ADDRESSING A TOTAL OF 3 OR MORE ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; AN EVOLVING CLINICAL PRESENTATION WITH CHANGING CHARACTERISTICS; AND CLINICAL DECISION MAKING OF MODERATE COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515807_1 CDM 424 RC 97162 HCPCS outpatient 218 163.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 194.02 89 999999999 170.04 207.1 percent of total billed charges "PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY OF PRESENT PROBLEM WITH 1-2 PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEMS USING STANDARDIZED TESTS AND MEASURES IN ADDRESSING A TOTAL OF 3 OR MORE ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; AN EVOLVING CLINICAL PRESENTATION WITH CHANGING CHARACTERISTICS; AND CLINICAL DECISION MAKING OF MODERATE COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515807_1 CDM 424 RC 97162 HCPCS outpatient 218 163.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 196.2 90 999999999 170.04 207.1 percent of total billed charges "PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY OF PRESENT PROBLEM WITH 1-2 PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEMS USING STANDARDIZED TESTS AND MEASURES IN ADDRESSING A TOTAL OF 3 OR MORE ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; AN EVOLVING CLINICAL PRESENTATION WITH CHANGING CHARACTERISTICS; AND CLINICAL DECISION MAKING OF MODERATE COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515807_1 CDM 424 RC 97162 HCPCS outpatient 218 163.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 207.1 95 999999999 170.04 207.1 percent of total billed charges "PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY OF PRESENT PROBLEM WITH 1-2 PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEMS USING STANDARDIZED TESTS AND MEASURES IN ADDRESSING A TOTAL OF 3 OR MORE ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; AN EVOLVING CLINICAL PRESENTATION WITH CHANGING CHARACTERISTICS; AND CLINICAL DECISION MAKING OF MODERATE COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515807_1 CDM 424 RC 97162 HCPCS outpatient 218 163.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 207.1 95 999999999 170.04 207.1 percent of total billed charges "PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY OF PRESENT PROBLEM WITH 1-2 PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEMS USING STANDARDIZED TESTS AND MEASURES IN ADDRESSING A TOTAL OF 3 OR MORE ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; AN EVOLVING CLINICAL PRESENTATION WITH CHANGING CHARACTERISTICS; AND CLINICAL DECISION MAKING OF MODERATE COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515807_1 CDM 424 RC 97162 HCPCS outpatient 218 163.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 194.02 89 999999999 170.04 207.1 percent of total billed charges "PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY OF PRESENT PROBLEM WITH 1-2 PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEMS USING STANDARDIZED TESTS AND MEASURES IN ADDRESSING A TOTAL OF 3 OR MORE ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; AN EVOLVING CLINICAL PRESENTATION WITH CHANGING CHARACTERISTICS; AND CLINICAL DECISION MAKING OF MODERATE COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515807_1 CDM 424 RC 97162 HCPCS outpatient 218 163.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 191.84 88 999999999 170.04 207.1 percent of total billed charges "PHYSICAL THERAPY EVALUATION: MODERATE COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY OF PRESENT PROBLEM WITH 1-2 PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEMS USING STANDARDIZED TESTS AND MEASURES IN ADDRESSING A TOTAL OF 3 OR MORE ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; AN EVOLVING CLINICAL PRESENTATION WITH CHANGING CHARACTERISTICS; AND CLINICAL DECISION MAKING OF MODERATE COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515807_1 CDM 424 RC 97162 HCPCS outpatient 218 163.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 194.02 89 999999999 170.04 207.1 percent of total billed charges "PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY OF PRESENT PROBLEM WITH 3 OR MORE PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEMS USING STANDARDIZED TESTS AND MEASURES ADDRESSING A TOTAL OF 4 OR MORE ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; A CLINICAL PRESENTATION WITH UNSTABLE AND UNPREDICTABLE CHARACTERISTICS; AND CLINICAL DECISION MAKING OF HIGH COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 45 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515808_1 CDM 424 RC 97163 HCPCS outpatient 236 177 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 212.4 90 999999999 184.08 224.2 percent of total billed charges "PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY OF PRESENT PROBLEM WITH 3 OR MORE PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEMS USING STANDARDIZED TESTS AND MEASURES ADDRESSING A TOTAL OF 4 OR MORE ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; A CLINICAL PRESENTATION WITH UNSTABLE AND UNPREDICTABLE CHARACTERISTICS; AND CLINICAL DECISION MAKING OF HIGH COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 45 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515808_1 CDM 424 RC 97163 HCPCS outpatient 236 177 AETNA MCR ADV AETNA MCR ADV 184.08 78 999999999 184.08 224.2 percent of total billed charges "PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY OF PRESENT PROBLEM WITH 3 OR MORE PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEMS USING STANDARDIZED TESTS AND MEASURES ADDRESSING A TOTAL OF 4 OR MORE ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; A CLINICAL PRESENTATION WITH UNSTABLE AND UNPREDICTABLE CHARACTERISTICS; AND CLINICAL DECISION MAKING OF HIGH COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 45 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515808_1 CDM 424 RC 97163 HCPCS outpatient 236 177 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 206.67 87.57 999999999 184.08 224.2 percent of total billed charges "PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY OF PRESENT PROBLEM WITH 3 OR MORE PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEMS USING STANDARDIZED TESTS AND MEASURES ADDRESSING A TOTAL OF 4 OR MORE ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; A CLINICAL PRESENTATION WITH UNSTABLE AND UNPREDICTABLE CHARACTERISTICS; AND CLINICAL DECISION MAKING OF HIGH COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 45 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515808_1 CDM 424 RC 97163 HCPCS outpatient 236 177 COORDINATED CARE MCAID COORDINATED CARE MCAID 200.77 85.07 999999999 184.08 224.2 percent of total billed charges "PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY OF PRESENT PROBLEM WITH 3 OR MORE PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEMS USING STANDARDIZED TESTS AND MEASURES ADDRESSING A TOTAL OF 4 OR MORE ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; A CLINICAL PRESENTATION WITH UNSTABLE AND UNPREDICTABLE CHARACTERISTICS; AND CLINICAL DECISION MAKING OF HIGH COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 45 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515808_1 CDM 424 RC 97163 HCPCS outpatient 236 177 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 200.77 85.07 999999999 184.08 224.2 percent of total billed charges "PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY OF PRESENT PROBLEM WITH 3 OR MORE PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEMS USING STANDARDIZED TESTS AND MEASURES ADDRESSING A TOTAL OF 4 OR MORE ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; A CLINICAL PRESENTATION WITH UNSTABLE AND UNPREDICTABLE CHARACTERISTICS; AND CLINICAL DECISION MAKING OF HIGH COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 45 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515808_1 CDM 424 RC 97163 HCPCS outpatient 236 177 MOLINA MCAID MOLINA MCAID 196.82 83.4 999999999 184.08 224.2 percent of total billed charges "PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY OF PRESENT PROBLEM WITH 3 OR MORE PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEMS USING STANDARDIZED TESTS AND MEASURES ADDRESSING A TOTAL OF 4 OR MORE ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; A CLINICAL PRESENTATION WITH UNSTABLE AND UNPREDICTABLE CHARACTERISTICS; AND CLINICAL DECISION MAKING OF HIGH COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 45 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515808_1 CDM 424 RC 97163 HCPCS outpatient 236 177 MOLINA MCR ADV MOLINA MCR ADV 210.04 89 999999999 184.08 224.2 percent of total billed charges "PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY OF PRESENT PROBLEM WITH 3 OR MORE PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEMS USING STANDARDIZED TESTS AND MEASURES ADDRESSING A TOTAL OF 4 OR MORE ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; A CLINICAL PRESENTATION WITH UNSTABLE AND UNPREDICTABLE CHARACTERISTICS; AND CLINICAL DECISION MAKING OF HIGH COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 45 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515808_1 CDM 424 RC 97163 HCPCS outpatient 236 177 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 210.04 89 999999999 184.08 224.2 percent of total billed charges "PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY OF PRESENT PROBLEM WITH 3 OR MORE PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEMS USING STANDARDIZED TESTS AND MEASURES ADDRESSING A TOTAL OF 4 OR MORE ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; A CLINICAL PRESENTATION WITH UNSTABLE AND UNPREDICTABLE CHARACTERISTICS; AND CLINICAL DECISION MAKING OF HIGH COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 45 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515808_1 CDM 424 RC 97163 HCPCS outpatient 236 177 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 210.04 89 999999999 184.08 224.2 percent of total billed charges "PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY OF PRESENT PROBLEM WITH 3 OR MORE PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEMS USING STANDARDIZED TESTS AND MEASURES ADDRESSING A TOTAL OF 4 OR MORE ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; A CLINICAL PRESENTATION WITH UNSTABLE AND UNPREDICTABLE CHARACTERISTICS; AND CLINICAL DECISION MAKING OF HIGH COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 45 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515808_1 CDM 424 RC 97163 HCPCS outpatient 236 177 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 212.4 90 999999999 184.08 224.2 percent of total billed charges "PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY OF PRESENT PROBLEM WITH 3 OR MORE PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEMS USING STANDARDIZED TESTS AND MEASURES ADDRESSING A TOTAL OF 4 OR MORE ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; A CLINICAL PRESENTATION WITH UNSTABLE AND UNPREDICTABLE CHARACTERISTICS; AND CLINICAL DECISION MAKING OF HIGH COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 45 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515808_1 CDM 424 RC 97163 HCPCS outpatient 236 177 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 224.2 95 999999999 184.08 224.2 percent of total billed charges "PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY OF PRESENT PROBLEM WITH 3 OR MORE PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEMS USING STANDARDIZED TESTS AND MEASURES ADDRESSING A TOTAL OF 4 OR MORE ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; A CLINICAL PRESENTATION WITH UNSTABLE AND UNPREDICTABLE CHARACTERISTICS; AND CLINICAL DECISION MAKING OF HIGH COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 45 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515808_1 CDM 424 RC 97163 HCPCS outpatient 236 177 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 224.2 95 999999999 184.08 224.2 percent of total billed charges "PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY OF PRESENT PROBLEM WITH 3 OR MORE PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEMS USING STANDARDIZED TESTS AND MEASURES ADDRESSING A TOTAL OF 4 OR MORE ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; A CLINICAL PRESENTATION WITH UNSTABLE AND UNPREDICTABLE CHARACTERISTICS; AND CLINICAL DECISION MAKING OF HIGH COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 45 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515808_1 CDM 424 RC 97163 HCPCS outpatient 236 177 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 210.04 89 999999999 184.08 224.2 percent of total billed charges "PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY OF PRESENT PROBLEM WITH 3 OR MORE PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEMS USING STANDARDIZED TESTS AND MEASURES ADDRESSING A TOTAL OF 4 OR MORE ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; A CLINICAL PRESENTATION WITH UNSTABLE AND UNPREDICTABLE CHARACTERISTICS; AND CLINICAL DECISION MAKING OF HIGH COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 45 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515808_1 CDM 424 RC 97163 HCPCS outpatient 236 177 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 207.68 88 999999999 184.08 224.2 percent of total billed charges "PHYSICAL THERAPY EVALUATION: HIGH COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY OF PRESENT PROBLEM WITH 3 OR MORE PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEMS USING STANDARDIZED TESTS AND MEASURES ADDRESSING A TOTAL OF 4 OR MORE ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; A CLINICAL PRESENTATION WITH UNSTABLE AND UNPREDICTABLE CHARACTERISTICS; AND CLINICAL DECISION MAKING OF HIGH COMPLEXITY USING STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME. TYPICALLY, 45 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515808_1 CDM 424 RC 97163 HCPCS outpatient 236 177 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 210.04 89 999999999 184.08 224.2 percent of total billed charges "RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE, REQUIRING THESE COMPONENTS: AN EXAMINATION INCLUDING A REVIEW OF HISTORY AND USE OF STANDARDIZED TESTS AND MEASURES IS REQUIRED; AND REVISED PLAN OF CARE USING A STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME TYPICALLY, 20 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515809_1 CDM 424 RC 97164 HCPCS outpatient 153 114.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 137.7 90 999999999 119.34 145.35 percent of total billed charges "RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE, REQUIRING THESE COMPONENTS: AN EXAMINATION INCLUDING A REVIEW OF HISTORY AND USE OF STANDARDIZED TESTS AND MEASURES IS REQUIRED; AND REVISED PLAN OF CARE USING A STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME TYPICALLY, 20 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515809_1 CDM 424 RC 97164 HCPCS outpatient 153 114.75 AETNA MCR ADV AETNA MCR ADV 119.34 78 999999999 119.34 145.35 percent of total billed charges "RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE, REQUIRING THESE COMPONENTS: AN EXAMINATION INCLUDING A REVIEW OF HISTORY AND USE OF STANDARDIZED TESTS AND MEASURES IS REQUIRED; AND REVISED PLAN OF CARE USING A STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME TYPICALLY, 20 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515809_1 CDM 424 RC 97164 HCPCS outpatient 153 114.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 133.98 87.57 999999999 119.34 145.35 percent of total billed charges "RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE, REQUIRING THESE COMPONENTS: AN EXAMINATION INCLUDING A REVIEW OF HISTORY AND USE OF STANDARDIZED TESTS AND MEASURES IS REQUIRED; AND REVISED PLAN OF CARE USING A STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME TYPICALLY, 20 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515809_1 CDM 424 RC 97164 HCPCS outpatient 153 114.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 130.16 85.07 999999999 119.34 145.35 percent of total billed charges "RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE, REQUIRING THESE COMPONENTS: AN EXAMINATION INCLUDING A REVIEW OF HISTORY AND USE OF STANDARDIZED TESTS AND MEASURES IS REQUIRED; AND REVISED PLAN OF CARE USING A STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME TYPICALLY, 20 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515809_1 CDM 424 RC 97164 HCPCS outpatient 153 114.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 130.16 85.07 999999999 119.34 145.35 percent of total billed charges "RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE, REQUIRING THESE COMPONENTS: AN EXAMINATION INCLUDING A REVIEW OF HISTORY AND USE OF STANDARDIZED TESTS AND MEASURES IS REQUIRED; AND REVISED PLAN OF CARE USING A STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME TYPICALLY, 20 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515809_1 CDM 424 RC 97164 HCPCS outpatient 153 114.75 MOLINA MCAID MOLINA MCAID 127.6 83.4 999999999 119.34 145.35 percent of total billed charges "RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE, REQUIRING THESE COMPONENTS: AN EXAMINATION INCLUDING A REVIEW OF HISTORY AND USE OF STANDARDIZED TESTS AND MEASURES IS REQUIRED; AND REVISED PLAN OF CARE USING A STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME TYPICALLY, 20 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515809_1 CDM 424 RC 97164 HCPCS outpatient 153 114.75 MOLINA MCR ADV MOLINA MCR ADV 136.17 89 999999999 119.34 145.35 percent of total billed charges "RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE, REQUIRING THESE COMPONENTS: AN EXAMINATION INCLUDING A REVIEW OF HISTORY AND USE OF STANDARDIZED TESTS AND MEASURES IS REQUIRED; AND REVISED PLAN OF CARE USING A STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME TYPICALLY, 20 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515809_1 CDM 424 RC 97164 HCPCS outpatient 153 114.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 136.17 89 999999999 119.34 145.35 percent of total billed charges "RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE, REQUIRING THESE COMPONENTS: AN EXAMINATION INCLUDING A REVIEW OF HISTORY AND USE OF STANDARDIZED TESTS AND MEASURES IS REQUIRED; AND REVISED PLAN OF CARE USING A STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME TYPICALLY, 20 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515809_1 CDM 424 RC 97164 HCPCS outpatient 153 114.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 136.17 89 999999999 119.34 145.35 percent of total billed charges "RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE, REQUIRING THESE COMPONENTS: AN EXAMINATION INCLUDING A REVIEW OF HISTORY AND USE OF STANDARDIZED TESTS AND MEASURES IS REQUIRED; AND REVISED PLAN OF CARE USING A STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME TYPICALLY, 20 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515809_1 CDM 424 RC 97164 HCPCS outpatient 153 114.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 137.7 90 999999999 119.34 145.35 percent of total billed charges "RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE, REQUIRING THESE COMPONENTS: AN EXAMINATION INCLUDING A REVIEW OF HISTORY AND USE OF STANDARDIZED TESTS AND MEASURES IS REQUIRED; AND REVISED PLAN OF CARE USING A STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME TYPICALLY, 20 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515809_1 CDM 424 RC 97164 HCPCS outpatient 153 114.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 145.35 95 999999999 119.34 145.35 percent of total billed charges "RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE, REQUIRING THESE COMPONENTS: AN EXAMINATION INCLUDING A REVIEW OF HISTORY AND USE OF STANDARDIZED TESTS AND MEASURES IS REQUIRED; AND REVISED PLAN OF CARE USING A STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME TYPICALLY, 20 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515809_1 CDM 424 RC 97164 HCPCS outpatient 153 114.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 145.35 95 999999999 119.34 145.35 percent of total billed charges "RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE, REQUIRING THESE COMPONENTS: AN EXAMINATION INCLUDING A REVIEW OF HISTORY AND USE OF STANDARDIZED TESTS AND MEASURES IS REQUIRED; AND REVISED PLAN OF CARE USING A STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME TYPICALLY, 20 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515809_1 CDM 424 RC 97164 HCPCS outpatient 153 114.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 136.17 89 999999999 119.34 145.35 percent of total billed charges "RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE, REQUIRING THESE COMPONENTS: AN EXAMINATION INCLUDING A REVIEW OF HISTORY AND USE OF STANDARDIZED TESTS AND MEASURES IS REQUIRED; AND REVISED PLAN OF CARE USING A STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME TYPICALLY, 20 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515809_1 CDM 424 RC 97164 HCPCS outpatient 153 114.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 134.64 88 999999999 119.34 145.35 percent of total billed charges "RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED PLAN OF CARE, REQUIRING THESE COMPONENTS: AN EXAMINATION INCLUDING A REVIEW OF HISTORY AND USE OF STANDARDIZED TESTS AND MEASURES IS REQUIRED; AND REVISED PLAN OF CARE USING A STANDARDIZED PATIENT ASSESSMENT INSTRUMENT AND/OR MEASURABLE ASSESSMENT OF FUNCTIONAL OUTCOME TYPICALLY, 20 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515809_1 CDM 424 RC 97164 HCPCS outpatient 153 114.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 136.17 89 999999999 119.34 145.35 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, LOW COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES A BRIEF HISTORY INCLUDING REVIEW OF MEDICAL AND/OR THERAPY RECORDS RELATING TO THE PRESENTING PROBLEM; AN ASSESSMENT(S) THAT IDENTIFIES 1-3 PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF LOW COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE OCCUPATIONAL PROFILE, ANALYSIS OF DATA FROM PROBLEM-FOCUSED ASSESSMENT(S), AND CONSIDERATION OF A LIMITED NUMBER OF TREATMENT OPTIONS. PATIENT PRESENTS WITH NO COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NOT NECESSARY TO ENABLE COMPLETION OF EVALUATION COMPONENT. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515810_1 CDM 434 RC 97165 HCPCS outpatient 184 138 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 165.6 90 999999999 143.52 174.8 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, LOW COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES A BRIEF HISTORY INCLUDING REVIEW OF MEDICAL AND/OR THERAPY RECORDS RELATING TO THE PRESENTING PROBLEM; AN ASSESSMENT(S) THAT IDENTIFIES 1-3 PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF LOW COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE OCCUPATIONAL PROFILE, ANALYSIS OF DATA FROM PROBLEM-FOCUSED ASSESSMENT(S), AND CONSIDERATION OF A LIMITED NUMBER OF TREATMENT OPTIONS. PATIENT PRESENTS WITH NO COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NOT NECESSARY TO ENABLE COMPLETION OF EVALUATION COMPONENT. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515810_1 CDM 434 RC 97165 HCPCS outpatient 184 138 AETNA MCR ADV AETNA MCR ADV 143.52 78 999999999 143.52 174.8 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, LOW COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES A BRIEF HISTORY INCLUDING REVIEW OF MEDICAL AND/OR THERAPY RECORDS RELATING TO THE PRESENTING PROBLEM; AN ASSESSMENT(S) THAT IDENTIFIES 1-3 PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF LOW COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE OCCUPATIONAL PROFILE, ANALYSIS OF DATA FROM PROBLEM-FOCUSED ASSESSMENT(S), AND CONSIDERATION OF A LIMITED NUMBER OF TREATMENT OPTIONS. PATIENT PRESENTS WITH NO COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NOT NECESSARY TO ENABLE COMPLETION OF EVALUATION COMPONENT. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515810_1 CDM 434 RC 97165 HCPCS outpatient 184 138 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 161.13 87.57 999999999 143.52 174.8 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, LOW COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES A BRIEF HISTORY INCLUDING REVIEW OF MEDICAL AND/OR THERAPY RECORDS RELATING TO THE PRESENTING PROBLEM; AN ASSESSMENT(S) THAT IDENTIFIES 1-3 PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF LOW COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE OCCUPATIONAL PROFILE, ANALYSIS OF DATA FROM PROBLEM-FOCUSED ASSESSMENT(S), AND CONSIDERATION OF A LIMITED NUMBER OF TREATMENT OPTIONS. PATIENT PRESENTS WITH NO COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NOT NECESSARY TO ENABLE COMPLETION OF EVALUATION COMPONENT. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515810_1 CDM 434 RC 97165 HCPCS outpatient 184 138 COORDINATED CARE MCAID COORDINATED CARE MCAID 156.53 85.07 999999999 143.52 174.8 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, LOW COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES A BRIEF HISTORY INCLUDING REVIEW OF MEDICAL AND/OR THERAPY RECORDS RELATING TO THE PRESENTING PROBLEM; AN ASSESSMENT(S) THAT IDENTIFIES 1-3 PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF LOW COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE OCCUPATIONAL PROFILE, ANALYSIS OF DATA FROM PROBLEM-FOCUSED ASSESSMENT(S), AND CONSIDERATION OF A LIMITED NUMBER OF TREATMENT OPTIONS. PATIENT PRESENTS WITH NO COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NOT NECESSARY TO ENABLE COMPLETION OF EVALUATION COMPONENT. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515810_1 CDM 434 RC 97165 HCPCS outpatient 184 138 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 156.53 85.07 999999999 143.52 174.8 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, LOW COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES A BRIEF HISTORY INCLUDING REVIEW OF MEDICAL AND/OR THERAPY RECORDS RELATING TO THE PRESENTING PROBLEM; AN ASSESSMENT(S) THAT IDENTIFIES 1-3 PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF LOW COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE OCCUPATIONAL PROFILE, ANALYSIS OF DATA FROM PROBLEM-FOCUSED ASSESSMENT(S), AND CONSIDERATION OF A LIMITED NUMBER OF TREATMENT OPTIONS. PATIENT PRESENTS WITH NO COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NOT NECESSARY TO ENABLE COMPLETION OF EVALUATION COMPONENT. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515810_1 CDM 434 RC 97165 HCPCS outpatient 184 138 MOLINA MCAID MOLINA MCAID 153.46 83.4 999999999 143.52 174.8 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, LOW COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES A BRIEF HISTORY INCLUDING REVIEW OF MEDICAL AND/OR THERAPY RECORDS RELATING TO THE PRESENTING PROBLEM; AN ASSESSMENT(S) THAT IDENTIFIES 1-3 PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF LOW COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE OCCUPATIONAL PROFILE, ANALYSIS OF DATA FROM PROBLEM-FOCUSED ASSESSMENT(S), AND CONSIDERATION OF A LIMITED NUMBER OF TREATMENT OPTIONS. PATIENT PRESENTS WITH NO COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NOT NECESSARY TO ENABLE COMPLETION OF EVALUATION COMPONENT. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515810_1 CDM 434 RC 97165 HCPCS outpatient 184 138 MOLINA MCR ADV MOLINA MCR ADV 163.76 89 999999999 143.52 174.8 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, LOW COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES A BRIEF HISTORY INCLUDING REVIEW OF MEDICAL AND/OR THERAPY RECORDS RELATING TO THE PRESENTING PROBLEM; AN ASSESSMENT(S) THAT IDENTIFIES 1-3 PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF LOW COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE OCCUPATIONAL PROFILE, ANALYSIS OF DATA FROM PROBLEM-FOCUSED ASSESSMENT(S), AND CONSIDERATION OF A LIMITED NUMBER OF TREATMENT OPTIONS. PATIENT PRESENTS WITH NO COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NOT NECESSARY TO ENABLE COMPLETION OF EVALUATION COMPONENT. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515810_1 CDM 434 RC 97165 HCPCS outpatient 184 138 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 163.76 89 999999999 143.52 174.8 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, LOW COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES A BRIEF HISTORY INCLUDING REVIEW OF MEDICAL AND/OR THERAPY RECORDS RELATING TO THE PRESENTING PROBLEM; AN ASSESSMENT(S) THAT IDENTIFIES 1-3 PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF LOW COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE OCCUPATIONAL PROFILE, ANALYSIS OF DATA FROM PROBLEM-FOCUSED ASSESSMENT(S), AND CONSIDERATION OF A LIMITED NUMBER OF TREATMENT OPTIONS. PATIENT PRESENTS WITH NO COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NOT NECESSARY TO ENABLE COMPLETION OF EVALUATION COMPONENT. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515810_1 CDM 434 RC 97165 HCPCS outpatient 184 138 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 163.76 89 999999999 143.52 174.8 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, LOW COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES A BRIEF HISTORY INCLUDING REVIEW OF MEDICAL AND/OR THERAPY RECORDS RELATING TO THE PRESENTING PROBLEM; AN ASSESSMENT(S) THAT IDENTIFIES 1-3 PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF LOW COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE OCCUPATIONAL PROFILE, ANALYSIS OF DATA FROM PROBLEM-FOCUSED ASSESSMENT(S), AND CONSIDERATION OF A LIMITED NUMBER OF TREATMENT OPTIONS. PATIENT PRESENTS WITH NO COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NOT NECESSARY TO ENABLE COMPLETION OF EVALUATION COMPONENT. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515810_1 CDM 434 RC 97165 HCPCS outpatient 184 138 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 165.6 90 999999999 143.52 174.8 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, LOW COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES A BRIEF HISTORY INCLUDING REVIEW OF MEDICAL AND/OR THERAPY RECORDS RELATING TO THE PRESENTING PROBLEM; AN ASSESSMENT(S) THAT IDENTIFIES 1-3 PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF LOW COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE OCCUPATIONAL PROFILE, ANALYSIS OF DATA FROM PROBLEM-FOCUSED ASSESSMENT(S), AND CONSIDERATION OF A LIMITED NUMBER OF TREATMENT OPTIONS. PATIENT PRESENTS WITH NO COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NOT NECESSARY TO ENABLE COMPLETION OF EVALUATION COMPONENT. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515810_1 CDM 434 RC 97165 HCPCS outpatient 184 138 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 174.8 95 999999999 143.52 174.8 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, LOW COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES A BRIEF HISTORY INCLUDING REVIEW OF MEDICAL AND/OR THERAPY RECORDS RELATING TO THE PRESENTING PROBLEM; AN ASSESSMENT(S) THAT IDENTIFIES 1-3 PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF LOW COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE OCCUPATIONAL PROFILE, ANALYSIS OF DATA FROM PROBLEM-FOCUSED ASSESSMENT(S), AND CONSIDERATION OF A LIMITED NUMBER OF TREATMENT OPTIONS. PATIENT PRESENTS WITH NO COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NOT NECESSARY TO ENABLE COMPLETION OF EVALUATION COMPONENT. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515810_1 CDM 434 RC 97165 HCPCS outpatient 184 138 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 174.8 95 999999999 143.52 174.8 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, LOW COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES A BRIEF HISTORY INCLUDING REVIEW OF MEDICAL AND/OR THERAPY RECORDS RELATING TO THE PRESENTING PROBLEM; AN ASSESSMENT(S) THAT IDENTIFIES 1-3 PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF LOW COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE OCCUPATIONAL PROFILE, ANALYSIS OF DATA FROM PROBLEM-FOCUSED ASSESSMENT(S), AND CONSIDERATION OF A LIMITED NUMBER OF TREATMENT OPTIONS. PATIENT PRESENTS WITH NO COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NOT NECESSARY TO ENABLE COMPLETION OF EVALUATION COMPONENT. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515810_1 CDM 434 RC 97165 HCPCS outpatient 184 138 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 163.76 89 999999999 143.52 174.8 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, LOW COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES A BRIEF HISTORY INCLUDING REVIEW OF MEDICAL AND/OR THERAPY RECORDS RELATING TO THE PRESENTING PROBLEM; AN ASSESSMENT(S) THAT IDENTIFIES 1-3 PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF LOW COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE OCCUPATIONAL PROFILE, ANALYSIS OF DATA FROM PROBLEM-FOCUSED ASSESSMENT(S), AND CONSIDERATION OF A LIMITED NUMBER OF TREATMENT OPTIONS. PATIENT PRESENTS WITH NO COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NOT NECESSARY TO ENABLE COMPLETION OF EVALUATION COMPONENT. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515810_1 CDM 434 RC 97165 HCPCS outpatient 184 138 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 161.92 88 999999999 143.52 174.8 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, LOW COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES A BRIEF HISTORY INCLUDING REVIEW OF MEDICAL AND/OR THERAPY RECORDS RELATING TO THE PRESENTING PROBLEM; AN ASSESSMENT(S) THAT IDENTIFIES 1-3 PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF LOW COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE OCCUPATIONAL PROFILE, ANALYSIS OF DATA FROM PROBLEM-FOCUSED ASSESSMENT(S), AND CONSIDERATION OF A LIMITED NUMBER OF TREATMENT OPTIONS. PATIENT PRESENTS WITH NO COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NOT NECESSARY TO ENABLE COMPLETION OF EVALUATION COMPONENT. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515810_1 CDM 434 RC 97165 HCPCS outpatient 184 138 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 163.76 89 999999999 143.52 174.8 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, MODERATE COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES AN EXPANDED REVIEW OF MEDICAL AND/OR THERAPY RECORDS AND ADDITIONAL REVIEW OF PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL HISTORY RELATED TO CURRENT FUNCTIONAL PERFORMANCE; AN ASSESSMENT(S) THAT IDENTIFIES 3-5 PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF MODERATE ANALYTIC COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE OCCUPATIONAL PROFILE, ANALYSIS OF DATA FROM DETAILED ASSESSMENT(S), AND CONSIDERATION OF SEVERAL TREATMENT OPTIONS. PATIENT MAY PRESENT WITH COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. MINIMAL TO MODERATE MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NECESSARY TO ENABLE PATIENT TO COMPLETE EVALUATION COMPONENT. TYPICALLY, 45 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515811_1 CDM 434 RC 97166 HCPCS outpatient 213 159.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 191.7 90 999999999 166.14 202.35 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, MODERATE COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES AN EXPANDED REVIEW OF MEDICAL AND/OR THERAPY RECORDS AND ADDITIONAL REVIEW OF PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL HISTORY RELATED TO CURRENT FUNCTIONAL PERFORMANCE; AN ASSESSMENT(S) THAT IDENTIFIES 3-5 PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF MODERATE ANALYTIC COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE OCCUPATIONAL PROFILE, ANALYSIS OF DATA FROM DETAILED ASSESSMENT(S), AND CONSIDERATION OF SEVERAL TREATMENT OPTIONS. PATIENT MAY PRESENT WITH COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. MINIMAL TO MODERATE MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NECESSARY TO ENABLE PATIENT TO COMPLETE EVALUATION COMPONENT. TYPICALLY, 45 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515811_1 CDM 434 RC 97166 HCPCS outpatient 213 159.75 AETNA MCR ADV AETNA MCR ADV 166.14 78 999999999 166.14 202.35 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, MODERATE COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES AN EXPANDED REVIEW OF MEDICAL AND/OR THERAPY RECORDS AND ADDITIONAL REVIEW OF PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL HISTORY RELATED TO CURRENT FUNCTIONAL PERFORMANCE; AN ASSESSMENT(S) THAT IDENTIFIES 3-5 PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF MODERATE ANALYTIC COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE OCCUPATIONAL PROFILE, ANALYSIS OF DATA FROM DETAILED ASSESSMENT(S), AND CONSIDERATION OF SEVERAL TREATMENT OPTIONS. PATIENT MAY PRESENT WITH COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. MINIMAL TO MODERATE MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NECESSARY TO ENABLE PATIENT TO COMPLETE EVALUATION COMPONENT. TYPICALLY, 45 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515811_1 CDM 434 RC 97166 HCPCS outpatient 213 159.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 186.52 87.57 999999999 166.14 202.35 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, MODERATE COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES AN EXPANDED REVIEW OF MEDICAL AND/OR THERAPY RECORDS AND ADDITIONAL REVIEW OF PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL HISTORY RELATED TO CURRENT FUNCTIONAL PERFORMANCE; AN ASSESSMENT(S) THAT IDENTIFIES 3-5 PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF MODERATE ANALYTIC COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE OCCUPATIONAL PROFILE, ANALYSIS OF DATA FROM DETAILED ASSESSMENT(S), AND CONSIDERATION OF SEVERAL TREATMENT OPTIONS. PATIENT MAY PRESENT WITH COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. MINIMAL TO MODERATE MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NECESSARY TO ENABLE PATIENT TO COMPLETE EVALUATION COMPONENT. TYPICALLY, 45 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515811_1 CDM 434 RC 97166 HCPCS outpatient 213 159.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 181.2 85.07 999999999 166.14 202.35 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, MODERATE COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES AN EXPANDED REVIEW OF MEDICAL AND/OR THERAPY RECORDS AND ADDITIONAL REVIEW OF PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL HISTORY RELATED TO CURRENT FUNCTIONAL PERFORMANCE; AN ASSESSMENT(S) THAT IDENTIFIES 3-5 PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF MODERATE ANALYTIC COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE OCCUPATIONAL PROFILE, ANALYSIS OF DATA FROM DETAILED ASSESSMENT(S), AND CONSIDERATION OF SEVERAL TREATMENT OPTIONS. PATIENT MAY PRESENT WITH COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. MINIMAL TO MODERATE MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NECESSARY TO ENABLE PATIENT TO COMPLETE EVALUATION COMPONENT. TYPICALLY, 45 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515811_1 CDM 434 RC 97166 HCPCS outpatient 213 159.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 181.2 85.07 999999999 166.14 202.35 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, MODERATE COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES AN EXPANDED REVIEW OF MEDICAL AND/OR THERAPY RECORDS AND ADDITIONAL REVIEW OF PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL HISTORY RELATED TO CURRENT FUNCTIONAL PERFORMANCE; AN ASSESSMENT(S) THAT IDENTIFIES 3-5 PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF MODERATE ANALYTIC COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE OCCUPATIONAL PROFILE, ANALYSIS OF DATA FROM DETAILED ASSESSMENT(S), AND CONSIDERATION OF SEVERAL TREATMENT OPTIONS. PATIENT MAY PRESENT WITH COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. MINIMAL TO MODERATE MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NECESSARY TO ENABLE PATIENT TO COMPLETE EVALUATION COMPONENT. TYPICALLY, 45 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515811_1 CDM 434 RC 97166 HCPCS outpatient 213 159.75 MOLINA MCAID MOLINA MCAID 177.64 83.4 999999999 166.14 202.35 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, MODERATE COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES AN EXPANDED REVIEW OF MEDICAL AND/OR THERAPY RECORDS AND ADDITIONAL REVIEW OF PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL HISTORY RELATED TO CURRENT FUNCTIONAL PERFORMANCE; AN ASSESSMENT(S) THAT IDENTIFIES 3-5 PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF MODERATE ANALYTIC COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE OCCUPATIONAL PROFILE, ANALYSIS OF DATA FROM DETAILED ASSESSMENT(S), AND CONSIDERATION OF SEVERAL TREATMENT OPTIONS. PATIENT MAY PRESENT WITH COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. MINIMAL TO MODERATE MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NECESSARY TO ENABLE PATIENT TO COMPLETE EVALUATION COMPONENT. TYPICALLY, 45 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515811_1 CDM 434 RC 97166 HCPCS outpatient 213 159.75 MOLINA MCR ADV MOLINA MCR ADV 189.57 89 999999999 166.14 202.35 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, MODERATE COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES AN EXPANDED REVIEW OF MEDICAL AND/OR THERAPY RECORDS AND ADDITIONAL REVIEW OF PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL HISTORY RELATED TO CURRENT FUNCTIONAL PERFORMANCE; AN ASSESSMENT(S) THAT IDENTIFIES 3-5 PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF MODERATE ANALYTIC COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE OCCUPATIONAL PROFILE, ANALYSIS OF DATA FROM DETAILED ASSESSMENT(S), AND CONSIDERATION OF SEVERAL TREATMENT OPTIONS. PATIENT MAY PRESENT WITH COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. MINIMAL TO MODERATE MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NECESSARY TO ENABLE PATIENT TO COMPLETE EVALUATION COMPONENT. TYPICALLY, 45 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515811_1 CDM 434 RC 97166 HCPCS outpatient 213 159.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 189.57 89 999999999 166.14 202.35 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, MODERATE COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES AN EXPANDED REVIEW OF MEDICAL AND/OR THERAPY RECORDS AND ADDITIONAL REVIEW OF PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL HISTORY RELATED TO CURRENT FUNCTIONAL PERFORMANCE; AN ASSESSMENT(S) THAT IDENTIFIES 3-5 PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF MODERATE ANALYTIC COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE OCCUPATIONAL PROFILE, ANALYSIS OF DATA FROM DETAILED ASSESSMENT(S), AND CONSIDERATION OF SEVERAL TREATMENT OPTIONS. PATIENT MAY PRESENT WITH COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. MINIMAL TO MODERATE MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NECESSARY TO ENABLE PATIENT TO COMPLETE EVALUATION COMPONENT. TYPICALLY, 45 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515811_1 CDM 434 RC 97166 HCPCS outpatient 213 159.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 189.57 89 999999999 166.14 202.35 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, MODERATE COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES AN EXPANDED REVIEW OF MEDICAL AND/OR THERAPY RECORDS AND ADDITIONAL REVIEW OF PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL HISTORY RELATED TO CURRENT FUNCTIONAL PERFORMANCE; AN ASSESSMENT(S) THAT IDENTIFIES 3-5 PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF MODERATE ANALYTIC COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE OCCUPATIONAL PROFILE, ANALYSIS OF DATA FROM DETAILED ASSESSMENT(S), AND CONSIDERATION OF SEVERAL TREATMENT OPTIONS. PATIENT MAY PRESENT WITH COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. MINIMAL TO MODERATE MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NECESSARY TO ENABLE PATIENT TO COMPLETE EVALUATION COMPONENT. TYPICALLY, 45 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515811_1 CDM 434 RC 97166 HCPCS outpatient 213 159.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 191.7 90 999999999 166.14 202.35 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, MODERATE COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES AN EXPANDED REVIEW OF MEDICAL AND/OR THERAPY RECORDS AND ADDITIONAL REVIEW OF PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL HISTORY RELATED TO CURRENT FUNCTIONAL PERFORMANCE; AN ASSESSMENT(S) THAT IDENTIFIES 3-5 PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF MODERATE ANALYTIC COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE OCCUPATIONAL PROFILE, ANALYSIS OF DATA FROM DETAILED ASSESSMENT(S), AND CONSIDERATION OF SEVERAL TREATMENT OPTIONS. PATIENT MAY PRESENT WITH COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. MINIMAL TO MODERATE MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NECESSARY TO ENABLE PATIENT TO COMPLETE EVALUATION COMPONENT. TYPICALLY, 45 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515811_1 CDM 434 RC 97166 HCPCS outpatient 213 159.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 202.35 95 999999999 166.14 202.35 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, MODERATE COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES AN EXPANDED REVIEW OF MEDICAL AND/OR THERAPY RECORDS AND ADDITIONAL REVIEW OF PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL HISTORY RELATED TO CURRENT FUNCTIONAL PERFORMANCE; AN ASSESSMENT(S) THAT IDENTIFIES 3-5 PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF MODERATE ANALYTIC COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE OCCUPATIONAL PROFILE, ANALYSIS OF DATA FROM DETAILED ASSESSMENT(S), AND CONSIDERATION OF SEVERAL TREATMENT OPTIONS. PATIENT MAY PRESENT WITH COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. MINIMAL TO MODERATE MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NECESSARY TO ENABLE PATIENT TO COMPLETE EVALUATION COMPONENT. TYPICALLY, 45 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515811_1 CDM 434 RC 97166 HCPCS outpatient 213 159.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 202.35 95 999999999 166.14 202.35 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, MODERATE COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES AN EXPANDED REVIEW OF MEDICAL AND/OR THERAPY RECORDS AND ADDITIONAL REVIEW OF PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL HISTORY RELATED TO CURRENT FUNCTIONAL PERFORMANCE; AN ASSESSMENT(S) THAT IDENTIFIES 3-5 PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF MODERATE ANALYTIC COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE OCCUPATIONAL PROFILE, ANALYSIS OF DATA FROM DETAILED ASSESSMENT(S), AND CONSIDERATION OF SEVERAL TREATMENT OPTIONS. PATIENT MAY PRESENT WITH COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. MINIMAL TO MODERATE MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NECESSARY TO ENABLE PATIENT TO COMPLETE EVALUATION COMPONENT. TYPICALLY, 45 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515811_1 CDM 434 RC 97166 HCPCS outpatient 213 159.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 189.57 89 999999999 166.14 202.35 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, MODERATE COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES AN EXPANDED REVIEW OF MEDICAL AND/OR THERAPY RECORDS AND ADDITIONAL REVIEW OF PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL HISTORY RELATED TO CURRENT FUNCTIONAL PERFORMANCE; AN ASSESSMENT(S) THAT IDENTIFIES 3-5 PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF MODERATE ANALYTIC COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE OCCUPATIONAL PROFILE, ANALYSIS OF DATA FROM DETAILED ASSESSMENT(S), AND CONSIDERATION OF SEVERAL TREATMENT OPTIONS. PATIENT MAY PRESENT WITH COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. MINIMAL TO MODERATE MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NECESSARY TO ENABLE PATIENT TO COMPLETE EVALUATION COMPONENT. TYPICALLY, 45 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515811_1 CDM 434 RC 97166 HCPCS outpatient 213 159.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 187.44 88 999999999 166.14 202.35 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, MODERATE COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES AN EXPANDED REVIEW OF MEDICAL AND/OR THERAPY RECORDS AND ADDITIONAL REVIEW OF PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL HISTORY RELATED TO CURRENT FUNCTIONAL PERFORMANCE; AN ASSESSMENT(S) THAT IDENTIFIES 3-5 PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF MODERATE ANALYTIC COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE OCCUPATIONAL PROFILE, ANALYSIS OF DATA FROM DETAILED ASSESSMENT(S), AND CONSIDERATION OF SEVERAL TREATMENT OPTIONS. PATIENT MAY PRESENT WITH COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. MINIMAL TO MODERATE MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NECESSARY TO ENABLE PATIENT TO COMPLETE EVALUATION COMPONENT. TYPICALLY, 45 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515811_1 CDM 434 RC 97166 HCPCS outpatient 213 159.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 189.57 89 999999999 166.14 202.35 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, HIGH COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES REVIEW OF MEDICAL AND/OR THERAPY RECORDS AND EXTENSIVE ADDITIONAL REVIEW OF PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL HISTORY RELATED TO CURRENT FUNCTIONAL PERFORMANCE; AN ASSESSMENT(S) THAT IDENTIFIES 5 OR MORE PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF HIGH ANALYTIC COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE PATIENT PROFILE, ANALYSIS OF DATA FROM COMPREHENSIVE ASSESSMENT(S), AND CONSIDERATION OF MULTIPLE TREATMENT OPTIONS. PATIENT PRESENTS WITH COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. SIGNIFICANT MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NECESSARY TO ENABLE PATIENT TO COMPLETE EVALUATION COMPONENT. TYPICALLY, 60 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515812_1 CDM 434 RC 97167 HCPCS outpatient 257 192.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 231.3 90 999999999 200.46 244.15 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, HIGH COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES REVIEW OF MEDICAL AND/OR THERAPY RECORDS AND EXTENSIVE ADDITIONAL REVIEW OF PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL HISTORY RELATED TO CURRENT FUNCTIONAL PERFORMANCE; AN ASSESSMENT(S) THAT IDENTIFIES 5 OR MORE PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF HIGH ANALYTIC COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE PATIENT PROFILE, ANALYSIS OF DATA FROM COMPREHENSIVE ASSESSMENT(S), AND CONSIDERATION OF MULTIPLE TREATMENT OPTIONS. PATIENT PRESENTS WITH COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. SIGNIFICANT MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NECESSARY TO ENABLE PATIENT TO COMPLETE EVALUATION COMPONENT. TYPICALLY, 60 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515812_1 CDM 434 RC 97167 HCPCS outpatient 257 192.75 AETNA MCR ADV AETNA MCR ADV 200.46 78 999999999 200.46 244.15 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, HIGH COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES REVIEW OF MEDICAL AND/OR THERAPY RECORDS AND EXTENSIVE ADDITIONAL REVIEW OF PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL HISTORY RELATED TO CURRENT FUNCTIONAL PERFORMANCE; AN ASSESSMENT(S) THAT IDENTIFIES 5 OR MORE PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF HIGH ANALYTIC COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE PATIENT PROFILE, ANALYSIS OF DATA FROM COMPREHENSIVE ASSESSMENT(S), AND CONSIDERATION OF MULTIPLE TREATMENT OPTIONS. PATIENT PRESENTS WITH COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. SIGNIFICANT MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NECESSARY TO ENABLE PATIENT TO COMPLETE EVALUATION COMPONENT. TYPICALLY, 60 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515812_1 CDM 434 RC 97167 HCPCS outpatient 257 192.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 225.05 87.57 999999999 200.46 244.15 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, HIGH COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES REVIEW OF MEDICAL AND/OR THERAPY RECORDS AND EXTENSIVE ADDITIONAL REVIEW OF PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL HISTORY RELATED TO CURRENT FUNCTIONAL PERFORMANCE; AN ASSESSMENT(S) THAT IDENTIFIES 5 OR MORE PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF HIGH ANALYTIC COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE PATIENT PROFILE, ANALYSIS OF DATA FROM COMPREHENSIVE ASSESSMENT(S), AND CONSIDERATION OF MULTIPLE TREATMENT OPTIONS. PATIENT PRESENTS WITH COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. SIGNIFICANT MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NECESSARY TO ENABLE PATIENT TO COMPLETE EVALUATION COMPONENT. TYPICALLY, 60 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515812_1 CDM 434 RC 97167 HCPCS outpatient 257 192.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 218.63 85.07 999999999 200.46 244.15 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, HIGH COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES REVIEW OF MEDICAL AND/OR THERAPY RECORDS AND EXTENSIVE ADDITIONAL REVIEW OF PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL HISTORY RELATED TO CURRENT FUNCTIONAL PERFORMANCE; AN ASSESSMENT(S) THAT IDENTIFIES 5 OR MORE PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF HIGH ANALYTIC COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE PATIENT PROFILE, ANALYSIS OF DATA FROM COMPREHENSIVE ASSESSMENT(S), AND CONSIDERATION OF MULTIPLE TREATMENT OPTIONS. PATIENT PRESENTS WITH COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. SIGNIFICANT MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NECESSARY TO ENABLE PATIENT TO COMPLETE EVALUATION COMPONENT. TYPICALLY, 60 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515812_1 CDM 434 RC 97167 HCPCS outpatient 257 192.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 218.63 85.07 999999999 200.46 244.15 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, HIGH COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES REVIEW OF MEDICAL AND/OR THERAPY RECORDS AND EXTENSIVE ADDITIONAL REVIEW OF PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL HISTORY RELATED TO CURRENT FUNCTIONAL PERFORMANCE; AN ASSESSMENT(S) THAT IDENTIFIES 5 OR MORE PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF HIGH ANALYTIC COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE PATIENT PROFILE, ANALYSIS OF DATA FROM COMPREHENSIVE ASSESSMENT(S), AND CONSIDERATION OF MULTIPLE TREATMENT OPTIONS. PATIENT PRESENTS WITH COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. SIGNIFICANT MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NECESSARY TO ENABLE PATIENT TO COMPLETE EVALUATION COMPONENT. TYPICALLY, 60 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515812_1 CDM 434 RC 97167 HCPCS outpatient 257 192.75 MOLINA MCAID MOLINA MCAID 214.34 83.4 999999999 200.46 244.15 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, HIGH COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES REVIEW OF MEDICAL AND/OR THERAPY RECORDS AND EXTENSIVE ADDITIONAL REVIEW OF PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL HISTORY RELATED TO CURRENT FUNCTIONAL PERFORMANCE; AN ASSESSMENT(S) THAT IDENTIFIES 5 OR MORE PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF HIGH ANALYTIC COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE PATIENT PROFILE, ANALYSIS OF DATA FROM COMPREHENSIVE ASSESSMENT(S), AND CONSIDERATION OF MULTIPLE TREATMENT OPTIONS. PATIENT PRESENTS WITH COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. SIGNIFICANT MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NECESSARY TO ENABLE PATIENT TO COMPLETE EVALUATION COMPONENT. TYPICALLY, 60 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515812_1 CDM 434 RC 97167 HCPCS outpatient 257 192.75 MOLINA MCR ADV MOLINA MCR ADV 228.73 89 999999999 200.46 244.15 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, HIGH COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES REVIEW OF MEDICAL AND/OR THERAPY RECORDS AND EXTENSIVE ADDITIONAL REVIEW OF PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL HISTORY RELATED TO CURRENT FUNCTIONAL PERFORMANCE; AN ASSESSMENT(S) THAT IDENTIFIES 5 OR MORE PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF HIGH ANALYTIC COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE PATIENT PROFILE, ANALYSIS OF DATA FROM COMPREHENSIVE ASSESSMENT(S), AND CONSIDERATION OF MULTIPLE TREATMENT OPTIONS. PATIENT PRESENTS WITH COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. SIGNIFICANT MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NECESSARY TO ENABLE PATIENT TO COMPLETE EVALUATION COMPONENT. TYPICALLY, 60 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515812_1 CDM 434 RC 97167 HCPCS outpatient 257 192.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 228.73 89 999999999 200.46 244.15 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, HIGH COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES REVIEW OF MEDICAL AND/OR THERAPY RECORDS AND EXTENSIVE ADDITIONAL REVIEW OF PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL HISTORY RELATED TO CURRENT FUNCTIONAL PERFORMANCE; AN ASSESSMENT(S) THAT IDENTIFIES 5 OR MORE PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF HIGH ANALYTIC COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE PATIENT PROFILE, ANALYSIS OF DATA FROM COMPREHENSIVE ASSESSMENT(S), AND CONSIDERATION OF MULTIPLE TREATMENT OPTIONS. PATIENT PRESENTS WITH COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. SIGNIFICANT MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NECESSARY TO ENABLE PATIENT TO COMPLETE EVALUATION COMPONENT. TYPICALLY, 60 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515812_1 CDM 434 RC 97167 HCPCS outpatient 257 192.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 228.73 89 999999999 200.46 244.15 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, HIGH COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES REVIEW OF MEDICAL AND/OR THERAPY RECORDS AND EXTENSIVE ADDITIONAL REVIEW OF PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL HISTORY RELATED TO CURRENT FUNCTIONAL PERFORMANCE; AN ASSESSMENT(S) THAT IDENTIFIES 5 OR MORE PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF HIGH ANALYTIC COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE PATIENT PROFILE, ANALYSIS OF DATA FROM COMPREHENSIVE ASSESSMENT(S), AND CONSIDERATION OF MULTIPLE TREATMENT OPTIONS. PATIENT PRESENTS WITH COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. SIGNIFICANT MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NECESSARY TO ENABLE PATIENT TO COMPLETE EVALUATION COMPONENT. TYPICALLY, 60 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515812_1 CDM 434 RC 97167 HCPCS outpatient 257 192.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 231.3 90 999999999 200.46 244.15 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, HIGH COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES REVIEW OF MEDICAL AND/OR THERAPY RECORDS AND EXTENSIVE ADDITIONAL REVIEW OF PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL HISTORY RELATED TO CURRENT FUNCTIONAL PERFORMANCE; AN ASSESSMENT(S) THAT IDENTIFIES 5 OR MORE PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF HIGH ANALYTIC COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE PATIENT PROFILE, ANALYSIS OF DATA FROM COMPREHENSIVE ASSESSMENT(S), AND CONSIDERATION OF MULTIPLE TREATMENT OPTIONS. PATIENT PRESENTS WITH COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. SIGNIFICANT MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NECESSARY TO ENABLE PATIENT TO COMPLETE EVALUATION COMPONENT. TYPICALLY, 60 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515812_1 CDM 434 RC 97167 HCPCS outpatient 257 192.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 244.15 95 999999999 200.46 244.15 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, HIGH COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES REVIEW OF MEDICAL AND/OR THERAPY RECORDS AND EXTENSIVE ADDITIONAL REVIEW OF PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL HISTORY RELATED TO CURRENT FUNCTIONAL PERFORMANCE; AN ASSESSMENT(S) THAT IDENTIFIES 5 OR MORE PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF HIGH ANALYTIC COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE PATIENT PROFILE, ANALYSIS OF DATA FROM COMPREHENSIVE ASSESSMENT(S), AND CONSIDERATION OF MULTIPLE TREATMENT OPTIONS. PATIENT PRESENTS WITH COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. SIGNIFICANT MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NECESSARY TO ENABLE PATIENT TO COMPLETE EVALUATION COMPONENT. TYPICALLY, 60 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515812_1 CDM 434 RC 97167 HCPCS outpatient 257 192.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 244.15 95 999999999 200.46 244.15 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, HIGH COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES REVIEW OF MEDICAL AND/OR THERAPY RECORDS AND EXTENSIVE ADDITIONAL REVIEW OF PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL HISTORY RELATED TO CURRENT FUNCTIONAL PERFORMANCE; AN ASSESSMENT(S) THAT IDENTIFIES 5 OR MORE PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF HIGH ANALYTIC COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE PATIENT PROFILE, ANALYSIS OF DATA FROM COMPREHENSIVE ASSESSMENT(S), AND CONSIDERATION OF MULTIPLE TREATMENT OPTIONS. PATIENT PRESENTS WITH COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. SIGNIFICANT MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NECESSARY TO ENABLE PATIENT TO COMPLETE EVALUATION COMPONENT. TYPICALLY, 60 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515812_1 CDM 434 RC 97167 HCPCS outpatient 257 192.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 228.73 89 999999999 200.46 244.15 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, HIGH COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES REVIEW OF MEDICAL AND/OR THERAPY RECORDS AND EXTENSIVE ADDITIONAL REVIEW OF PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL HISTORY RELATED TO CURRENT FUNCTIONAL PERFORMANCE; AN ASSESSMENT(S) THAT IDENTIFIES 5 OR MORE PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF HIGH ANALYTIC COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE PATIENT PROFILE, ANALYSIS OF DATA FROM COMPREHENSIVE ASSESSMENT(S), AND CONSIDERATION OF MULTIPLE TREATMENT OPTIONS. PATIENT PRESENTS WITH COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. SIGNIFICANT MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NECESSARY TO ENABLE PATIENT TO COMPLETE EVALUATION COMPONENT. TYPICALLY, 60 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515812_1 CDM 434 RC 97167 HCPCS outpatient 257 192.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 226.16 88 999999999 200.46 244.15 percent of total billed charges "OCCUPATIONAL THERAPY EVALUATION, HIGH COMPLEXITY, REQUIRING THESE COMPONENTS: AN OCCUPATIONAL PROFILE AND MEDICAL AND THERAPY HISTORY, WHICH INCLUDES REVIEW OF MEDICAL AND/OR THERAPY RECORDS AND EXTENSIVE ADDITIONAL REVIEW OF PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL HISTORY RELATED TO CURRENT FUNCTIONAL PERFORMANCE; AN ASSESSMENT(S) THAT IDENTIFIES 5 OR MORE PERFORMANCE DEFICITS (IE, RELATING TO PHYSICAL, COGNITIVE, OR PSYCHOSOCIAL SKILLS) THAT RESULT IN ACTIVITY LIMITATIONS AND/OR PARTICIPATION RESTRICTIONS; AND CLINICAL DECISION MAKING OF HIGH ANALYTIC COMPLEXITY, WHICH INCLUDES AN ANALYSIS OF THE PATIENT PROFILE, ANALYSIS OF DATA FROM COMPREHENSIVE ASSESSMENT(S), AND CONSIDERATION OF MULTIPLE TREATMENT OPTIONS. PATIENT PRESENTS WITH COMORBIDITIES THAT AFFECT OCCUPATIONAL PERFORMANCE. SIGNIFICANT MODIFICATION OF TASKS OR ASSISTANCE (EG, PHYSICAL OR VERBAL) WITH ASSESSMENT(S) IS NECESSARY TO ENABLE PATIENT TO COMPLETE EVALUATION COMPONENT. TYPICALLY, 60 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515812_1 CDM 434 RC 97167 HCPCS outpatient 257 192.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 228.73 89 999999999 200.46 244.15 percent of total billed charges "RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CARE, REQUIRING THESE COMPONENTS: AN ASSESSMENT OF CHANGES IN PATIENT FUNCTIONAL OR MEDICAL STATUS WITH REVISED PLAN OF CARE; AN UPDATE TO THE INITIAL OCCUPATIONAL PROFILE TO REFLECT CHANGES IN CONDITION OR ENVIRONMENT THAT AFFECT FUTURE INTERVENTIONS AND/OR GOALS; AND A REVISED PLAN OF CARE. A FORMAL REEVALUATION IS PERFORMED WHEN THERE IS A DOCUMENTED CHANGE IN FUNCTIONAL STATUS OR A SIGNIFICANT CHANGE TO THE PLAN OF CARE IS REQUIRED. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515813_1 CDM 434 RC 97168 HCPCS outpatient 113 84.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 101.7 90 999999999 88.14 107.35 percent of total billed charges "RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CARE, REQUIRING THESE COMPONENTS: AN ASSESSMENT OF CHANGES IN PATIENT FUNCTIONAL OR MEDICAL STATUS WITH REVISED PLAN OF CARE; AN UPDATE TO THE INITIAL OCCUPATIONAL PROFILE TO REFLECT CHANGES IN CONDITION OR ENVIRONMENT THAT AFFECT FUTURE INTERVENTIONS AND/OR GOALS; AND A REVISED PLAN OF CARE. A FORMAL REEVALUATION IS PERFORMED WHEN THERE IS A DOCUMENTED CHANGE IN FUNCTIONAL STATUS OR A SIGNIFICANT CHANGE TO THE PLAN OF CARE IS REQUIRED. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515813_1 CDM 434 RC 97168 HCPCS outpatient 113 84.75 AETNA MCR ADV AETNA MCR ADV 88.14 78 999999999 88.14 107.35 percent of total billed charges "RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CARE, REQUIRING THESE COMPONENTS: AN ASSESSMENT OF CHANGES IN PATIENT FUNCTIONAL OR MEDICAL STATUS WITH REVISED PLAN OF CARE; AN UPDATE TO THE INITIAL OCCUPATIONAL PROFILE TO REFLECT CHANGES IN CONDITION OR ENVIRONMENT THAT AFFECT FUTURE INTERVENTIONS AND/OR GOALS; AND A REVISED PLAN OF CARE. A FORMAL REEVALUATION IS PERFORMED WHEN THERE IS A DOCUMENTED CHANGE IN FUNCTIONAL STATUS OR A SIGNIFICANT CHANGE TO THE PLAN OF CARE IS REQUIRED. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515813_1 CDM 434 RC 97168 HCPCS outpatient 113 84.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 98.95 87.57 999999999 88.14 107.35 percent of total billed charges "RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CARE, REQUIRING THESE COMPONENTS: AN ASSESSMENT OF CHANGES IN PATIENT FUNCTIONAL OR MEDICAL STATUS WITH REVISED PLAN OF CARE; AN UPDATE TO THE INITIAL OCCUPATIONAL PROFILE TO REFLECT CHANGES IN CONDITION OR ENVIRONMENT THAT AFFECT FUTURE INTERVENTIONS AND/OR GOALS; AND A REVISED PLAN OF CARE. A FORMAL REEVALUATION IS PERFORMED WHEN THERE IS A DOCUMENTED CHANGE IN FUNCTIONAL STATUS OR A SIGNIFICANT CHANGE TO THE PLAN OF CARE IS REQUIRED. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515813_1 CDM 434 RC 97168 HCPCS outpatient 113 84.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 96.13 85.07 999999999 88.14 107.35 percent of total billed charges "RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CARE, REQUIRING THESE COMPONENTS: AN ASSESSMENT OF CHANGES IN PATIENT FUNCTIONAL OR MEDICAL STATUS WITH REVISED PLAN OF CARE; AN UPDATE TO THE INITIAL OCCUPATIONAL PROFILE TO REFLECT CHANGES IN CONDITION OR ENVIRONMENT THAT AFFECT FUTURE INTERVENTIONS AND/OR GOALS; AND A REVISED PLAN OF CARE. A FORMAL REEVALUATION IS PERFORMED WHEN THERE IS A DOCUMENTED CHANGE IN FUNCTIONAL STATUS OR A SIGNIFICANT CHANGE TO THE PLAN OF CARE IS REQUIRED. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515813_1 CDM 434 RC 97168 HCPCS outpatient 113 84.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 96.13 85.07 999999999 88.14 107.35 percent of total billed charges "RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CARE, REQUIRING THESE COMPONENTS: AN ASSESSMENT OF CHANGES IN PATIENT FUNCTIONAL OR MEDICAL STATUS WITH REVISED PLAN OF CARE; AN UPDATE TO THE INITIAL OCCUPATIONAL PROFILE TO REFLECT CHANGES IN CONDITION OR ENVIRONMENT THAT AFFECT FUTURE INTERVENTIONS AND/OR GOALS; AND A REVISED PLAN OF CARE. A FORMAL REEVALUATION IS PERFORMED WHEN THERE IS A DOCUMENTED CHANGE IN FUNCTIONAL STATUS OR A SIGNIFICANT CHANGE TO THE PLAN OF CARE IS REQUIRED. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515813_1 CDM 434 RC 97168 HCPCS outpatient 113 84.75 MOLINA MCAID MOLINA MCAID 94.24 83.4 999999999 88.14 107.35 percent of total billed charges "RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CARE, REQUIRING THESE COMPONENTS: AN ASSESSMENT OF CHANGES IN PATIENT FUNCTIONAL OR MEDICAL STATUS WITH REVISED PLAN OF CARE; AN UPDATE TO THE INITIAL OCCUPATIONAL PROFILE TO REFLECT CHANGES IN CONDITION OR ENVIRONMENT THAT AFFECT FUTURE INTERVENTIONS AND/OR GOALS; AND A REVISED PLAN OF CARE. A FORMAL REEVALUATION IS PERFORMED WHEN THERE IS A DOCUMENTED CHANGE IN FUNCTIONAL STATUS OR A SIGNIFICANT CHANGE TO THE PLAN OF CARE IS REQUIRED. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515813_1 CDM 434 RC 97168 HCPCS outpatient 113 84.75 MOLINA MCR ADV MOLINA MCR ADV 100.57 89 999999999 88.14 107.35 percent of total billed charges "RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CARE, REQUIRING THESE COMPONENTS: AN ASSESSMENT OF CHANGES IN PATIENT FUNCTIONAL OR MEDICAL STATUS WITH REVISED PLAN OF CARE; AN UPDATE TO THE INITIAL OCCUPATIONAL PROFILE TO REFLECT CHANGES IN CONDITION OR ENVIRONMENT THAT AFFECT FUTURE INTERVENTIONS AND/OR GOALS; AND A REVISED PLAN OF CARE. A FORMAL REEVALUATION IS PERFORMED WHEN THERE IS A DOCUMENTED CHANGE IN FUNCTIONAL STATUS OR A SIGNIFICANT CHANGE TO THE PLAN OF CARE IS REQUIRED. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515813_1 CDM 434 RC 97168 HCPCS outpatient 113 84.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 100.57 89 999999999 88.14 107.35 percent of total billed charges "RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CARE, REQUIRING THESE COMPONENTS: AN ASSESSMENT OF CHANGES IN PATIENT FUNCTIONAL OR MEDICAL STATUS WITH REVISED PLAN OF CARE; AN UPDATE TO THE INITIAL OCCUPATIONAL PROFILE TO REFLECT CHANGES IN CONDITION OR ENVIRONMENT THAT AFFECT FUTURE INTERVENTIONS AND/OR GOALS; AND A REVISED PLAN OF CARE. A FORMAL REEVALUATION IS PERFORMED WHEN THERE IS A DOCUMENTED CHANGE IN FUNCTIONAL STATUS OR A SIGNIFICANT CHANGE TO THE PLAN OF CARE IS REQUIRED. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515813_1 CDM 434 RC 97168 HCPCS outpatient 113 84.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 100.57 89 999999999 88.14 107.35 percent of total billed charges "RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CARE, REQUIRING THESE COMPONENTS: AN ASSESSMENT OF CHANGES IN PATIENT FUNCTIONAL OR MEDICAL STATUS WITH REVISED PLAN OF CARE; AN UPDATE TO THE INITIAL OCCUPATIONAL PROFILE TO REFLECT CHANGES IN CONDITION OR ENVIRONMENT THAT AFFECT FUTURE INTERVENTIONS AND/OR GOALS; AND A REVISED PLAN OF CARE. A FORMAL REEVALUATION IS PERFORMED WHEN THERE IS A DOCUMENTED CHANGE IN FUNCTIONAL STATUS OR A SIGNIFICANT CHANGE TO THE PLAN OF CARE IS REQUIRED. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515813_1 CDM 434 RC 97168 HCPCS outpatient 113 84.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 101.7 90 999999999 88.14 107.35 percent of total billed charges "RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CARE, REQUIRING THESE COMPONENTS: AN ASSESSMENT OF CHANGES IN PATIENT FUNCTIONAL OR MEDICAL STATUS WITH REVISED PLAN OF CARE; AN UPDATE TO THE INITIAL OCCUPATIONAL PROFILE TO REFLECT CHANGES IN CONDITION OR ENVIRONMENT THAT AFFECT FUTURE INTERVENTIONS AND/OR GOALS; AND A REVISED PLAN OF CARE. A FORMAL REEVALUATION IS PERFORMED WHEN THERE IS A DOCUMENTED CHANGE IN FUNCTIONAL STATUS OR A SIGNIFICANT CHANGE TO THE PLAN OF CARE IS REQUIRED. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515813_1 CDM 434 RC 97168 HCPCS outpatient 113 84.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 107.35 95 999999999 88.14 107.35 percent of total billed charges "RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CARE, REQUIRING THESE COMPONENTS: AN ASSESSMENT OF CHANGES IN PATIENT FUNCTIONAL OR MEDICAL STATUS WITH REVISED PLAN OF CARE; AN UPDATE TO THE INITIAL OCCUPATIONAL PROFILE TO REFLECT CHANGES IN CONDITION OR ENVIRONMENT THAT AFFECT FUTURE INTERVENTIONS AND/OR GOALS; AND A REVISED PLAN OF CARE. A FORMAL REEVALUATION IS PERFORMED WHEN THERE IS A DOCUMENTED CHANGE IN FUNCTIONAL STATUS OR A SIGNIFICANT CHANGE TO THE PLAN OF CARE IS REQUIRED. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515813_1 CDM 434 RC 97168 HCPCS outpatient 113 84.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 107.35 95 999999999 88.14 107.35 percent of total billed charges "RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CARE, REQUIRING THESE COMPONENTS: AN ASSESSMENT OF CHANGES IN PATIENT FUNCTIONAL OR MEDICAL STATUS WITH REVISED PLAN OF CARE; AN UPDATE TO THE INITIAL OCCUPATIONAL PROFILE TO REFLECT CHANGES IN CONDITION OR ENVIRONMENT THAT AFFECT FUTURE INTERVENTIONS AND/OR GOALS; AND A REVISED PLAN OF CARE. A FORMAL REEVALUATION IS PERFORMED WHEN THERE IS A DOCUMENTED CHANGE IN FUNCTIONAL STATUS OR A SIGNIFICANT CHANGE TO THE PLAN OF CARE IS REQUIRED. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515813_1 CDM 434 RC 97168 HCPCS outpatient 113 84.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 100.57 89 999999999 88.14 107.35 percent of total billed charges "RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CARE, REQUIRING THESE COMPONENTS: AN ASSESSMENT OF CHANGES IN PATIENT FUNCTIONAL OR MEDICAL STATUS WITH REVISED PLAN OF CARE; AN UPDATE TO THE INITIAL OCCUPATIONAL PROFILE TO REFLECT CHANGES IN CONDITION OR ENVIRONMENT THAT AFFECT FUTURE INTERVENTIONS AND/OR GOALS; AND A REVISED PLAN OF CARE. A FORMAL REEVALUATION IS PERFORMED WHEN THERE IS A DOCUMENTED CHANGE IN FUNCTIONAL STATUS OR A SIGNIFICANT CHANGE TO THE PLAN OF CARE IS REQUIRED. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515813_1 CDM 434 RC 97168 HCPCS outpatient 113 84.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 99.44 88 999999999 88.14 107.35 percent of total billed charges "RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CARE, REQUIRING THESE COMPONENTS: AN ASSESSMENT OF CHANGES IN PATIENT FUNCTIONAL OR MEDICAL STATUS WITH REVISED PLAN OF CARE; AN UPDATE TO THE INITIAL OCCUPATIONAL PROFILE TO REFLECT CHANGES IN CONDITION OR ENVIRONMENT THAT AFFECT FUTURE INTERVENTIONS AND/OR GOALS; AND A REVISED PLAN OF CARE. A FORMAL REEVALUATION IS PERFORMED WHEN THERE IS A DOCUMENTED CHANGE IN FUNCTIONAL STATUS OR A SIGNIFICANT CHANGE TO THE PLAN OF CARE IS REQUIRED. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY." 9515813_1 CDM 434 RC 97168 HCPCS outpatient 113 84.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 100.57 89 999999999 88.14 107.35 percent of total billed charges "INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)" 9515823_1 CDM 361 RC 62321 HCPCS outpatient 2009 1506.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1808.1 999999999 1567.02 1908.55 case rate "INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)" 9515823_1 CDM 361 RC 62321 HCPCS outpatient 2009 1506.75 AETNA MCR ADV AETNA MCR ADV 1567.02 78 999999999 1567.02 1908.55 percent of total billed charges "INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)" 9515823_1 CDM 361 RC 62321 HCPCS outpatient 2009 1506.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1759.28 87.57 999999999 1567.02 1908.55 percent of total billed charges "INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)" 9515823_1 CDM 361 RC 62321 HCPCS outpatient 2009 1506.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 1709.06 85.07 999999999 1567.02 1908.55 percent of total billed charges "INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)" 9515823_1 CDM 361 RC 62321 HCPCS outpatient 2009 1506.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1709.06 85.07 999999999 1567.02 1908.55 percent of total billed charges "INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)" 9515823_1 CDM 361 RC 62321 HCPCS outpatient 2009 1506.75 MOLINA MCAID MOLINA MCAID 1675.51 83.4 999999999 1567.02 1908.55 percent of total billed charges "INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)" 9515823_1 CDM 361 RC 62321 HCPCS outpatient 2009 1506.75 MOLINA MCR ADV MOLINA MCR ADV 1788.01 89 999999999 1567.02 1908.55 percent of total billed charges "INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)" 9515823_1 CDM 361 RC 62321 HCPCS outpatient 2009 1506.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1788.01 89 999999999 1567.02 1908.55 percent of total billed charges "INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)" 9515823_1 CDM 361 RC 62321 HCPCS outpatient 2009 1506.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1788.01 89 999999999 1567.02 1908.55 percent of total billed charges "INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)" 9515823_1 CDM 361 RC 62321 HCPCS outpatient 2009 1506.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1808.1 90 999999999 1567.02 1908.55 percent of total billed charges "INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)" 9515823_1 CDM 361 RC 62321 HCPCS outpatient 2009 1506.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1908.55 95 999999999 1567.02 1908.55 percent of total billed charges "INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)" 9515823_1 CDM 361 RC 62321 HCPCS outpatient 2009 1506.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1908.55 95 999999999 1567.02 1908.55 percent of total billed charges "INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)" 9515823_1 CDM 361 RC 62321 HCPCS outpatient 2009 1506.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1788.01 89 999999999 1567.02 1908.55 percent of total billed charges "INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)" 9515823_1 CDM 361 RC 62321 HCPCS outpatient 2009 1506.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1767.92 88 999999999 1567.02 1908.55 percent of total billed charges "INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)" 9515823_1 CDM 361 RC 62321 HCPCS outpatient 2009 1506.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1788.01 89 999999999 1567.02 1908.55 percent of total billed charges "RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW" 9515847_1 CDM 324 RC 71045 HCPCS outpatient 234 175.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 210.6 90 999999999 182.52 222.3 percent of total billed charges "RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW" 9515847_1 CDM 324 RC 71045 HCPCS outpatient 234 175.5 AETNA MCR ADV AETNA MCR ADV 182.52 78 999999999 182.52 222.3 percent of total billed charges "RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW" 9515847_1 CDM 324 RC 71045 HCPCS outpatient 234 175.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 204.91 87.57 999999999 182.52 222.3 percent of total billed charges "RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW" 9515847_1 CDM 324 RC 71045 HCPCS outpatient 234 175.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 199.06 85.07 999999999 182.52 222.3 percent of total billed charges "RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW" 9515847_1 CDM 324 RC 71045 HCPCS outpatient 234 175.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 199.06 85.07 999999999 182.52 222.3 percent of total billed charges "RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW" 9515847_1 CDM 324 RC 71045 HCPCS outpatient 234 175.5 MOLINA MCAID MOLINA MCAID 195.16 83.4 999999999 182.52 222.3 percent of total billed charges "RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW" 9515847_1 CDM 324 RC 71045 HCPCS outpatient 234 175.5 MOLINA MCR ADV MOLINA MCR ADV 208.26 89 999999999 182.52 222.3 percent of total billed charges "RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW" 9515847_1 CDM 324 RC 71045 HCPCS outpatient 234 175.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 208.26 89 999999999 182.52 222.3 percent of total billed charges "RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW" 9515847_1 CDM 324 RC 71045 HCPCS outpatient 234 175.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 208.26 89 999999999 182.52 222.3 percent of total billed charges "RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW" 9515847_1 CDM 324 RC 71045 HCPCS outpatient 234 175.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 210.6 90 999999999 182.52 222.3 percent of total billed charges "RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW" 9515847_1 CDM 324 RC 71045 HCPCS outpatient 234 175.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 222.3 95 999999999 182.52 222.3 percent of total billed charges "RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW" 9515847_1 CDM 324 RC 71045 HCPCS outpatient 234 175.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 222.3 95 999999999 182.52 222.3 percent of total billed charges "RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW" 9515847_1 CDM 324 RC 71045 HCPCS outpatient 234 175.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 208.26 89 999999999 182.52 222.3 percent of total billed charges "RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW" 9515847_1 CDM 324 RC 71045 HCPCS outpatient 234 175.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 205.92 88 999999999 182.52 222.3 percent of total billed charges "RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW" 9515847_1 CDM 324 RC 71045 HCPCS outpatient 234 175.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 208.26 89 999999999 182.52 222.3 percent of total billed charges "RADIOLOGIC EXAMINATION, CHEST; 2 VIEWS" 9515848_1 CDM 324 RC 71046 HCPCS outpatient 311 233.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 279.9 90 999999999 242.58 295.45 percent of total billed charges "RADIOLOGIC EXAMINATION, CHEST; 2 VIEWS" 9515848_1 CDM 324 RC 71046 HCPCS outpatient 311 233.25 AETNA MCR ADV AETNA MCR ADV 242.58 78 999999999 242.58 295.45 percent of total billed charges "RADIOLOGIC EXAMINATION, CHEST; 2 VIEWS" 9515848_1 CDM 324 RC 71046 HCPCS outpatient 311 233.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 272.34 87.57 999999999 242.58 295.45 percent of total billed charges "RADIOLOGIC EXAMINATION, CHEST; 2 VIEWS" 9515848_1 CDM 324 RC 71046 HCPCS outpatient 311 233.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 264.57 85.07 999999999 242.58 295.45 percent of total billed charges "RADIOLOGIC EXAMINATION, CHEST; 2 VIEWS" 9515848_1 CDM 324 RC 71046 HCPCS outpatient 311 233.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 264.57 85.07 999999999 242.58 295.45 percent of total billed charges "RADIOLOGIC EXAMINATION, CHEST; 2 VIEWS" 9515848_1 CDM 324 RC 71046 HCPCS outpatient 311 233.25 MOLINA MCAID MOLINA MCAID 259.37 83.4 999999999 242.58 295.45 percent of total billed charges "RADIOLOGIC EXAMINATION, CHEST; 2 VIEWS" 9515848_1 CDM 324 RC 71046 HCPCS outpatient 311 233.25 MOLINA MCR ADV MOLINA MCR ADV 276.79 89 999999999 242.58 295.45 percent of total billed charges "RADIOLOGIC EXAMINATION, CHEST; 2 VIEWS" 9515848_1 CDM 324 RC 71046 HCPCS outpatient 311 233.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 276.79 89 999999999 242.58 295.45 percent of total billed charges "RADIOLOGIC EXAMINATION, CHEST; 2 VIEWS" 9515848_1 CDM 324 RC 71046 HCPCS outpatient 311 233.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 276.79 89 999999999 242.58 295.45 percent of total billed charges "RADIOLOGIC EXAMINATION, CHEST; 2 VIEWS" 9515848_1 CDM 324 RC 71046 HCPCS outpatient 311 233.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 279.9 90 999999999 242.58 295.45 percent of total billed charges "RADIOLOGIC EXAMINATION, CHEST; 2 VIEWS" 9515848_1 CDM 324 RC 71046 HCPCS outpatient 311 233.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 295.45 95 999999999 242.58 295.45 percent of total billed charges "RADIOLOGIC EXAMINATION, CHEST; 2 VIEWS" 9515848_1 CDM 324 RC 71046 HCPCS outpatient 311 233.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 295.45 95 999999999 242.58 295.45 percent of total billed charges "RADIOLOGIC EXAMINATION, CHEST; 2 VIEWS" 9515848_1 CDM 324 RC 71046 HCPCS outpatient 311 233.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 276.79 89 999999999 242.58 295.45 percent of total billed charges "RADIOLOGIC EXAMINATION, CHEST; 2 VIEWS" 9515848_1 CDM 324 RC 71046 HCPCS outpatient 311 233.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 273.68 88 999999999 242.58 295.45 percent of total billed charges "RADIOLOGIC EXAMINATION, CHEST; 2 VIEWS" 9515848_1 CDM 324 RC 71046 HCPCS outpatient 311 233.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 276.79 89 999999999 242.58 295.45 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 1 VIEW" 9515851_1 CDM 320 RC 74018 HCPCS outpatient 281 210.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 252.9 90 999999999 219.18 266.95 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 1 VIEW" 9515851_1 CDM 320 RC 74018 HCPCS outpatient 281 210.75 AETNA MCR ADV AETNA MCR ADV 219.18 78 999999999 219.18 266.95 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 1 VIEW" 9515851_1 CDM 320 RC 74018 HCPCS outpatient 281 210.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 246.07 87.57 999999999 219.18 266.95 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 1 VIEW" 9515851_1 CDM 320 RC 74018 HCPCS outpatient 281 210.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 239.05 85.07 999999999 219.18 266.95 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 1 VIEW" 9515851_1 CDM 320 RC 74018 HCPCS outpatient 281 210.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 239.05 85.07 999999999 219.18 266.95 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 1 VIEW" 9515851_1 CDM 320 RC 74018 HCPCS outpatient 281 210.75 MOLINA MCAID MOLINA MCAID 234.35 83.4 999999999 219.18 266.95 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 1 VIEW" 9515851_1 CDM 320 RC 74018 HCPCS outpatient 281 210.75 MOLINA MCR ADV MOLINA MCR ADV 250.09 89 999999999 219.18 266.95 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 1 VIEW" 9515851_1 CDM 320 RC 74018 HCPCS outpatient 281 210.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 250.09 89 999999999 219.18 266.95 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 1 VIEW" 9515851_1 CDM 320 RC 74018 HCPCS outpatient 281 210.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 250.09 89 999999999 219.18 266.95 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 1 VIEW" 9515851_1 CDM 320 RC 74018 HCPCS outpatient 281 210.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 252.9 90 999999999 219.18 266.95 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 1 VIEW" 9515851_1 CDM 320 RC 74018 HCPCS outpatient 281 210.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 266.95 95 999999999 219.18 266.95 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 1 VIEW" 9515851_1 CDM 320 RC 74018 HCPCS outpatient 281 210.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 266.95 95 999999999 219.18 266.95 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 1 VIEW" 9515851_1 CDM 320 RC 74018 HCPCS outpatient 281 210.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 250.09 89 999999999 219.18 266.95 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 1 VIEW" 9515851_1 CDM 320 RC 74018 HCPCS outpatient 281 210.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 247.28 88 999999999 219.18 266.95 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 1 VIEW" 9515851_1 CDM 320 RC 74018 HCPCS outpatient 281 210.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 250.09 89 999999999 219.18 266.95 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 2 VIEWS" 9515852_1 CDM 320 RC 74019 HCPCS outpatient 401 300.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 360.9 90 999999999 312.78 380.95 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 2 VIEWS" 9515852_1 CDM 320 RC 74019 HCPCS outpatient 401 300.75 AETNA MCR ADV AETNA MCR ADV 312.78 78 999999999 312.78 380.95 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 2 VIEWS" 9515852_1 CDM 320 RC 74019 HCPCS outpatient 401 300.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 351.16 87.57 999999999 312.78 380.95 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 2 VIEWS" 9515852_1 CDM 320 RC 74019 HCPCS outpatient 401 300.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 341.13 85.07 999999999 312.78 380.95 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 2 VIEWS" 9515852_1 CDM 320 RC 74019 HCPCS outpatient 401 300.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 341.13 85.07 999999999 312.78 380.95 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 2 VIEWS" 9515852_1 CDM 320 RC 74019 HCPCS outpatient 401 300.75 MOLINA MCAID MOLINA MCAID 334.43 83.4 999999999 312.78 380.95 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 2 VIEWS" 9515852_1 CDM 320 RC 74019 HCPCS outpatient 401 300.75 MOLINA MCR ADV MOLINA MCR ADV 356.89 89 999999999 312.78 380.95 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 2 VIEWS" 9515852_1 CDM 320 RC 74019 HCPCS outpatient 401 300.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 356.89 89 999999999 312.78 380.95 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 2 VIEWS" 9515852_1 CDM 320 RC 74019 HCPCS outpatient 401 300.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 356.89 89 999999999 312.78 380.95 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 2 VIEWS" 9515852_1 CDM 320 RC 74019 HCPCS outpatient 401 300.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 360.9 90 999999999 312.78 380.95 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 2 VIEWS" 9515852_1 CDM 320 RC 74019 HCPCS outpatient 401 300.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 380.95 95 999999999 312.78 380.95 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 2 VIEWS" 9515852_1 CDM 320 RC 74019 HCPCS outpatient 401 300.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 380.95 95 999999999 312.78 380.95 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 2 VIEWS" 9515852_1 CDM 320 RC 74019 HCPCS outpatient 401 300.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 356.89 89 999999999 312.78 380.95 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 2 VIEWS" 9515852_1 CDM 320 RC 74019 HCPCS outpatient 401 300.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 352.88 88 999999999 312.78 380.95 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 2 VIEWS" 9515852_1 CDM 320 RC 74019 HCPCS outpatient 401 300.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 356.89 89 999999999 312.78 380.95 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 3 OR MORE VIEWS" 9515853_1 CDM 320 RC 74021 HCPCS outpatient 412 309 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 370.8 90 999999999 321.36 391.4 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 3 OR MORE VIEWS" 9515853_1 CDM 320 RC 74021 HCPCS outpatient 412 309 AETNA MCR ADV AETNA MCR ADV 321.36 78 999999999 321.36 391.4 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 3 OR MORE VIEWS" 9515853_1 CDM 320 RC 74021 HCPCS outpatient 412 309 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 360.79 87.57 999999999 321.36 391.4 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 3 OR MORE VIEWS" 9515853_1 CDM 320 RC 74021 HCPCS outpatient 412 309 COORDINATED CARE MCAID COORDINATED CARE MCAID 350.49 85.07 999999999 321.36 391.4 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 3 OR MORE VIEWS" 9515853_1 CDM 320 RC 74021 HCPCS outpatient 412 309 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 350.49 85.07 999999999 321.36 391.4 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 3 OR MORE VIEWS" 9515853_1 CDM 320 RC 74021 HCPCS outpatient 412 309 MOLINA MCAID MOLINA MCAID 343.61 83.4 999999999 321.36 391.4 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 3 OR MORE VIEWS" 9515853_1 CDM 320 RC 74021 HCPCS outpatient 412 309 MOLINA MCR ADV MOLINA MCR ADV 366.68 89 999999999 321.36 391.4 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 3 OR MORE VIEWS" 9515853_1 CDM 320 RC 74021 HCPCS outpatient 412 309 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 366.68 89 999999999 321.36 391.4 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 3 OR MORE VIEWS" 9515853_1 CDM 320 RC 74021 HCPCS outpatient 412 309 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 366.68 89 999999999 321.36 391.4 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 3 OR MORE VIEWS" 9515853_1 CDM 320 RC 74021 HCPCS outpatient 412 309 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 370.8 90 999999999 321.36 391.4 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 3 OR MORE VIEWS" 9515853_1 CDM 320 RC 74021 HCPCS outpatient 412 309 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 391.4 95 999999999 321.36 391.4 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 3 OR MORE VIEWS" 9515853_1 CDM 320 RC 74021 HCPCS outpatient 412 309 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 391.4 95 999999999 321.36 391.4 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 3 OR MORE VIEWS" 9515853_1 CDM 320 RC 74021 HCPCS outpatient 412 309 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 366.68 89 999999999 321.36 391.4 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 3 OR MORE VIEWS" 9515853_1 CDM 320 RC 74021 HCPCS outpatient 412 309 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 362.56 88 999999999 321.36 391.4 percent of total billed charges "RADIOLOGIC EXAMINATION, ABDOMEN; 3 OR MORE VIEWS" 9515853_1 CDM 320 RC 74021 HCPCS outpatient 412 309 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 366.68 89 999999999 321.36 391.4 percent of total billed charges TRAUMA RESPONSE TEAM ASSOCIATED WITH HOSPITAL CRITICAL CARE SERVICE 9515884_2 CDM 684 RC G0390 HCPCS outpatient 1902 1426.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1711.8 90 999999999 1483.56 1806.9 percent of total billed charges TRAUMA RESPONSE TEAM ASSOCIATED WITH HOSPITAL CRITICAL CARE SERVICE 9515884_2 CDM 684 RC G0390 HCPCS outpatient 1902 1426.5 AETNA MCR ADV AETNA MCR ADV 1483.56 78 999999999 1483.56 1806.9 percent of total billed charges TRAUMA RESPONSE TEAM ASSOCIATED WITH HOSPITAL CRITICAL CARE SERVICE 9515884_2 CDM 684 RC G0390 HCPCS outpatient 1902 1426.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1665.58 87.57 999999999 1483.56 1806.9 percent of total billed charges TRAUMA RESPONSE TEAM ASSOCIATED WITH HOSPITAL CRITICAL CARE SERVICE 9515884_2 CDM 684 RC G0390 HCPCS outpatient 1902 1426.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 1618.03 85.07 999999999 1483.56 1806.9 percent of total billed charges TRAUMA RESPONSE TEAM ASSOCIATED WITH HOSPITAL CRITICAL CARE SERVICE 9515884_2 CDM 684 RC G0390 HCPCS outpatient 1902 1426.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1618.03 85.07 999999999 1483.56 1806.9 percent of total billed charges TRAUMA RESPONSE TEAM ASSOCIATED WITH HOSPITAL CRITICAL CARE SERVICE 9515884_2 CDM 684 RC G0390 HCPCS outpatient 1902 1426.5 MOLINA MCAID MOLINA MCAID 1586.27 83.4 999999999 1483.56 1806.9 percent of total billed charges TRAUMA RESPONSE TEAM ASSOCIATED WITH HOSPITAL CRITICAL CARE SERVICE 9515884_2 CDM 684 RC G0390 HCPCS outpatient 1902 1426.5 MOLINA MCR ADV MOLINA MCR ADV 1692.78 89 999999999 1483.56 1806.9 percent of total billed charges TRAUMA RESPONSE TEAM ASSOCIATED WITH HOSPITAL CRITICAL CARE SERVICE 9515884_2 CDM 684 RC G0390 HCPCS outpatient 1902 1426.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1692.78 89 999999999 1483.56 1806.9 percent of total billed charges TRAUMA RESPONSE TEAM ASSOCIATED WITH HOSPITAL CRITICAL CARE SERVICE 9515884_2 CDM 684 RC G0390 HCPCS outpatient 1902 1426.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1692.78 89 999999999 1483.56 1806.9 percent of total billed charges TRAUMA RESPONSE TEAM ASSOCIATED WITH HOSPITAL CRITICAL CARE SERVICE 9515884_2 CDM 684 RC G0390 HCPCS outpatient 1902 1426.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1711.8 90 999999999 1483.56 1806.9 percent of total billed charges TRAUMA RESPONSE TEAM ASSOCIATED WITH HOSPITAL CRITICAL CARE SERVICE 9515884_2 CDM 684 RC G0390 HCPCS outpatient 1902 1426.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1806.9 95 999999999 1483.56 1806.9 percent of total billed charges TRAUMA RESPONSE TEAM ASSOCIATED WITH HOSPITAL CRITICAL CARE SERVICE 9515884_2 CDM 684 RC G0390 HCPCS outpatient 1902 1426.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1806.9 95 999999999 1483.56 1806.9 percent of total billed charges TRAUMA RESPONSE TEAM ASSOCIATED WITH HOSPITAL CRITICAL CARE SERVICE 9515884_2 CDM 684 RC G0390 HCPCS outpatient 1902 1426.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1692.78 89 999999999 1483.56 1806.9 percent of total billed charges TRAUMA RESPONSE TEAM ASSOCIATED WITH HOSPITAL CRITICAL CARE SERVICE 9515884_2 CDM 684 RC G0390 HCPCS outpatient 1902 1426.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1673.76 88 999999999 1483.56 1806.9 percent of total billed charges TRAUMA RESPONSE TEAM ASSOCIATED WITH HOSPITAL CRITICAL CARE SERVICE 9515884_2 CDM 684 RC G0390 HCPCS outpatient 1902 1426.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1692.78 89 999999999 1483.56 1806.9 percent of total billed charges "MAXIMUM BREATHING CAPACITY, MAXIMAL VOLUNTARY VENTILATION" 9515889_1 CDM 460 RC 94200 HCPCS outpatient 221 165.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 198.9 90 999999999 172.38 209.95 percent of total billed charges "MAXIMUM BREATHING CAPACITY, MAXIMAL VOLUNTARY VENTILATION" 9515889_1 CDM 460 RC 94200 HCPCS outpatient 221 165.75 AETNA MCR ADV AETNA MCR ADV 172.38 78 999999999 172.38 209.95 percent of total billed charges "MAXIMUM BREATHING CAPACITY, MAXIMAL VOLUNTARY VENTILATION" 9515889_1 CDM 460 RC 94200 HCPCS outpatient 221 165.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 193.53 87.57 999999999 172.38 209.95 percent of total billed charges "MAXIMUM BREATHING CAPACITY, MAXIMAL VOLUNTARY VENTILATION" 9515889_1 CDM 460 RC 94200 HCPCS outpatient 221 165.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 188 85.07 999999999 172.38 209.95 percent of total billed charges "MAXIMUM BREATHING CAPACITY, MAXIMAL VOLUNTARY VENTILATION" 9515889_1 CDM 460 RC 94200 HCPCS outpatient 221 165.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 188 85.07 999999999 172.38 209.95 percent of total billed charges "MAXIMUM BREATHING CAPACITY, MAXIMAL VOLUNTARY VENTILATION" 9515889_1 CDM 460 RC 94200 HCPCS outpatient 221 165.75 MOLINA MCAID MOLINA MCAID 184.31 83.4 999999999 172.38 209.95 percent of total billed charges "MAXIMUM BREATHING CAPACITY, MAXIMAL VOLUNTARY VENTILATION" 9515889_1 CDM 460 RC 94200 HCPCS outpatient 221 165.75 MOLINA MCR ADV MOLINA MCR ADV 196.69 89 999999999 172.38 209.95 percent of total billed charges "MAXIMUM BREATHING CAPACITY, MAXIMAL VOLUNTARY VENTILATION" 9515889_1 CDM 460 RC 94200 HCPCS outpatient 221 165.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 196.69 89 999999999 172.38 209.95 percent of total billed charges "MAXIMUM BREATHING CAPACITY, MAXIMAL VOLUNTARY VENTILATION" 9515889_1 CDM 460 RC 94200 HCPCS outpatient 221 165.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 196.69 89 999999999 172.38 209.95 percent of total billed charges "MAXIMUM BREATHING CAPACITY, MAXIMAL VOLUNTARY VENTILATION" 9515889_1 CDM 460 RC 94200 HCPCS outpatient 221 165.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 198.9 90 999999999 172.38 209.95 percent of total billed charges "MAXIMUM BREATHING CAPACITY, MAXIMAL VOLUNTARY VENTILATION" 9515889_1 CDM 460 RC 94200 HCPCS outpatient 221 165.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 209.95 95 999999999 172.38 209.95 percent of total billed charges "MAXIMUM BREATHING CAPACITY, MAXIMAL VOLUNTARY VENTILATION" 9515889_1 CDM 460 RC 94200 HCPCS outpatient 221 165.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 209.95 95 999999999 172.38 209.95 percent of total billed charges "MAXIMUM BREATHING CAPACITY, MAXIMAL VOLUNTARY VENTILATION" 9515889_1 CDM 460 RC 94200 HCPCS outpatient 221 165.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 196.69 89 999999999 172.38 209.95 percent of total billed charges "MAXIMUM BREATHING CAPACITY, MAXIMAL VOLUNTARY VENTILATION" 9515889_1 CDM 460 RC 94200 HCPCS outpatient 221 165.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 194.48 88 999999999 172.38 209.95 percent of total billed charges "MAXIMUM BREATHING CAPACITY, MAXIMAL VOLUNTARY VENTILATION" 9515889_1 CDM 460 RC 94200 HCPCS outpatient 221 165.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 196.69 89 999999999 172.38 209.95 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 9515901_1 CDM 361 RC 23655 HCPCS outpatient 970 727.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 873 999999999 756.6 921.5 case rate "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 9515901_1 CDM 361 RC 23655 HCPCS outpatient 970 727.5 AETNA MCR ADV AETNA MCR ADV 756.6 78 999999999 756.6 921.5 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 9515901_1 CDM 361 RC 23655 HCPCS outpatient 970 727.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 849.43 87.57 999999999 756.6 921.5 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 9515901_1 CDM 361 RC 23655 HCPCS outpatient 970 727.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 825.18 85.07 999999999 756.6 921.5 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 9515901_1 CDM 361 RC 23655 HCPCS outpatient 970 727.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 825.18 85.07 999999999 756.6 921.5 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 9515901_1 CDM 361 RC 23655 HCPCS outpatient 970 727.5 MOLINA MCAID MOLINA MCAID 808.98 83.4 999999999 756.6 921.5 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 9515901_1 CDM 361 RC 23655 HCPCS outpatient 970 727.5 MOLINA MCR ADV MOLINA MCR ADV 863.3 89 999999999 756.6 921.5 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 9515901_1 CDM 361 RC 23655 HCPCS outpatient 970 727.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 863.3 89 999999999 756.6 921.5 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 9515901_1 CDM 361 RC 23655 HCPCS outpatient 970 727.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 863.3 89 999999999 756.6 921.5 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 9515901_1 CDM 361 RC 23655 HCPCS outpatient 970 727.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 873 90 999999999 756.6 921.5 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 9515901_1 CDM 361 RC 23655 HCPCS outpatient 970 727.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 921.5 95 999999999 756.6 921.5 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 9515901_1 CDM 361 RC 23655 HCPCS outpatient 970 727.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 921.5 95 999999999 756.6 921.5 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 9515901_1 CDM 361 RC 23655 HCPCS outpatient 970 727.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 863.3 89 999999999 756.6 921.5 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 9515901_1 CDM 361 RC 23655 HCPCS outpatient 970 727.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 853.6 88 999999999 756.6 921.5 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA" 9515901_1 CDM 361 RC 23655 HCPCS outpatient 970 727.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 863.3 89 999999999 756.6 921.5 percent of total billed charges CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT 9515907_1 CDM 361 RC 21480 HCPCS outpatient 881 660.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 792.9 999999999 687.18 836.95 case rate CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT 9515907_1 CDM 361 RC 21480 HCPCS outpatient 881 660.75 AETNA MCR ADV AETNA MCR ADV 687.18 78 999999999 687.18 836.95 percent of total billed charges CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT 9515907_1 CDM 361 RC 21480 HCPCS outpatient 881 660.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 771.49 87.57 999999999 687.18 836.95 percent of total billed charges CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT 9515907_1 CDM 361 RC 21480 HCPCS outpatient 881 660.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 749.47 85.07 999999999 687.18 836.95 percent of total billed charges CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT 9515907_1 CDM 361 RC 21480 HCPCS outpatient 881 660.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 749.47 85.07 999999999 687.18 836.95 percent of total billed charges CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT 9515907_1 CDM 361 RC 21480 HCPCS outpatient 881 660.75 MOLINA MCAID MOLINA MCAID 734.75 83.4 999999999 687.18 836.95 percent of total billed charges CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT 9515907_1 CDM 361 RC 21480 HCPCS outpatient 881 660.75 MOLINA MCR ADV MOLINA MCR ADV 784.09 89 999999999 687.18 836.95 percent of total billed charges CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT 9515907_1 CDM 361 RC 21480 HCPCS outpatient 881 660.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 784.09 89 999999999 687.18 836.95 percent of total billed charges CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT 9515907_1 CDM 361 RC 21480 HCPCS outpatient 881 660.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 784.09 89 999999999 687.18 836.95 percent of total billed charges CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT 9515907_1 CDM 361 RC 21480 HCPCS outpatient 881 660.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 792.9 90 999999999 687.18 836.95 percent of total billed charges CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT 9515907_1 CDM 361 RC 21480 HCPCS outpatient 881 660.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 836.95 95 999999999 687.18 836.95 percent of total billed charges CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT 9515907_1 CDM 361 RC 21480 HCPCS outpatient 881 660.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 836.95 95 999999999 687.18 836.95 percent of total billed charges CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT 9515907_1 CDM 361 RC 21480 HCPCS outpatient 881 660.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 784.09 89 999999999 687.18 836.95 percent of total billed charges CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT 9515907_1 CDM 361 RC 21480 HCPCS outpatient 881 660.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 775.28 88 999999999 687.18 836.95 percent of total billed charges CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT 9515907_1 CDM 361 RC 21480 HCPCS outpatient 881 660.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 784.09 89 999999999 687.18 836.95 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 9515920_1 CDM 361 RC 65210 HCPCS outpatient 316 237 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 284.4 999999999 246.48 300.2 case rate "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 9515920_1 CDM 361 RC 65210 HCPCS outpatient 316 237 AETNA MCR ADV AETNA MCR ADV 246.48 78 999999999 246.48 300.2 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 9515920_1 CDM 361 RC 65210 HCPCS outpatient 316 237 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 276.72 87.57 999999999 246.48 300.2 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 9515920_1 CDM 361 RC 65210 HCPCS outpatient 316 237 COORDINATED CARE MCAID COORDINATED CARE MCAID 268.82 85.07 999999999 246.48 300.2 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 9515920_1 CDM 361 RC 65210 HCPCS outpatient 316 237 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 268.82 85.07 999999999 246.48 300.2 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 9515920_1 CDM 361 RC 65210 HCPCS outpatient 316 237 MOLINA MCAID MOLINA MCAID 263.54 83.4 999999999 246.48 300.2 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 9515920_1 CDM 361 RC 65210 HCPCS outpatient 316 237 MOLINA MCR ADV MOLINA MCR ADV 281.24 89 999999999 246.48 300.2 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 9515920_1 CDM 361 RC 65210 HCPCS outpatient 316 237 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 281.24 89 999999999 246.48 300.2 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 9515920_1 CDM 361 RC 65210 HCPCS outpatient 316 237 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 281.24 89 999999999 246.48 300.2 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 9515920_1 CDM 361 RC 65210 HCPCS outpatient 316 237 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 284.4 90 999999999 246.48 300.2 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 9515920_1 CDM 361 RC 65210 HCPCS outpatient 316 237 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 300.2 95 999999999 246.48 300.2 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 9515920_1 CDM 361 RC 65210 HCPCS outpatient 316 237 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 300.2 95 999999999 246.48 300.2 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 9515920_1 CDM 361 RC 65210 HCPCS outpatient 316 237 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 281.24 89 999999999 246.48 300.2 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 9515920_1 CDM 361 RC 65210 HCPCS outpatient 316 237 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 278.08 88 999999999 246.48 300.2 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING" 9515920_1 CDM 361 RC 65210 HCPCS outpatient 316 237 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 281.24 89 999999999 246.48 300.2 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE 9515947_1 CDM 361 RC 12020 HCPCS outpatient 1038 778.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 934.2 999999999 809.64 986.1 case rate TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE 9515947_1 CDM 361 RC 12020 HCPCS outpatient 1038 778.5 AETNA MCR ADV AETNA MCR ADV 809.64 78 999999999 809.64 986.1 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE 9515947_1 CDM 361 RC 12020 HCPCS outpatient 1038 778.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 908.98 87.57 999999999 809.64 986.1 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE 9515947_1 CDM 361 RC 12020 HCPCS outpatient 1038 778.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 883.03 85.07 999999999 809.64 986.1 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE 9515947_1 CDM 361 RC 12020 HCPCS outpatient 1038 778.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 883.03 85.07 999999999 809.64 986.1 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE 9515947_1 CDM 361 RC 12020 HCPCS outpatient 1038 778.5 MOLINA MCAID MOLINA MCAID 865.69 83.4 999999999 809.64 986.1 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE 9515947_1 CDM 361 RC 12020 HCPCS outpatient 1038 778.5 MOLINA MCR ADV MOLINA MCR ADV 923.82 89 999999999 809.64 986.1 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE 9515947_1 CDM 361 RC 12020 HCPCS outpatient 1038 778.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 923.82 89 999999999 809.64 986.1 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE 9515947_1 CDM 361 RC 12020 HCPCS outpatient 1038 778.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 923.82 89 999999999 809.64 986.1 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE 9515947_1 CDM 361 RC 12020 HCPCS outpatient 1038 778.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 934.2 90 999999999 809.64 986.1 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE 9515947_1 CDM 361 RC 12020 HCPCS outpatient 1038 778.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 986.1 95 999999999 809.64 986.1 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE 9515947_1 CDM 361 RC 12020 HCPCS outpatient 1038 778.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 986.1 95 999999999 809.64 986.1 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE 9515947_1 CDM 361 RC 12020 HCPCS outpatient 1038 778.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 923.82 89 999999999 809.64 986.1 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE 9515947_1 CDM 361 RC 12020 HCPCS outpatient 1038 778.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 913.44 88 999999999 809.64 986.1 percent of total billed charges TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE 9515947_1 CDM 361 RC 12020 HCPCS outpatient 1038 778.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 923.82 89 999999999 809.64 986.1 percent of total billed charges PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION 9515956_1 CDM 361 RC 36680 HCPCS outpatient 338 253.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 304.2 999999999 263.64 321.1 case rate PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION 9515956_1 CDM 361 RC 36680 HCPCS outpatient 338 253.5 AETNA MCR ADV AETNA MCR ADV 263.64 78 999999999 263.64 321.1 percent of total billed charges PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION 9515956_1 CDM 361 RC 36680 HCPCS outpatient 338 253.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 295.99 87.57 999999999 263.64 321.1 percent of total billed charges PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION 9515956_1 CDM 361 RC 36680 HCPCS outpatient 338 253.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 287.54 85.07 999999999 263.64 321.1 percent of total billed charges PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION 9515956_1 CDM 361 RC 36680 HCPCS outpatient 338 253.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 287.54 85.07 999999999 263.64 321.1 percent of total billed charges PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION 9515956_1 CDM 361 RC 36680 HCPCS outpatient 338 253.5 MOLINA MCAID MOLINA MCAID 281.89 83.4 999999999 263.64 321.1 percent of total billed charges PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION 9515956_1 CDM 361 RC 36680 HCPCS outpatient 338 253.5 MOLINA MCR ADV MOLINA MCR ADV 300.82 89 999999999 263.64 321.1 percent of total billed charges PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION 9515956_1 CDM 361 RC 36680 HCPCS outpatient 338 253.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 300.82 89 999999999 263.64 321.1 percent of total billed charges PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION 9515956_1 CDM 361 RC 36680 HCPCS outpatient 338 253.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 300.82 89 999999999 263.64 321.1 percent of total billed charges PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION 9515956_1 CDM 361 RC 36680 HCPCS outpatient 338 253.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 304.2 90 999999999 263.64 321.1 percent of total billed charges PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION 9515956_1 CDM 361 RC 36680 HCPCS outpatient 338 253.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 321.1 95 999999999 263.64 321.1 percent of total billed charges PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION 9515956_1 CDM 361 RC 36680 HCPCS outpatient 338 253.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 321.1 95 999999999 263.64 321.1 percent of total billed charges PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION 9515956_1 CDM 361 RC 36680 HCPCS outpatient 338 253.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 300.82 89 999999999 263.64 321.1 percent of total billed charges PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION 9515956_1 CDM 361 RC 36680 HCPCS outpatient 338 253.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 297.44 88 999999999 263.64 321.1 percent of total billed charges PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION 9515956_1 CDM 361 RC 36680 HCPCS outpatient 338 253.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 300.82 89 999999999 263.64 321.1 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9515992_1 CDM 361 RC 12035 HCPCS outpatient 931 698.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 837.9 999999999 726.18 884.45 case rate "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9515992_1 CDM 361 RC 12035 HCPCS outpatient 931 698.25 AETNA MCR ADV AETNA MCR ADV 726.18 78 999999999 726.18 884.45 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9515992_1 CDM 361 RC 12035 HCPCS outpatient 931 698.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 815.28 87.57 999999999 726.18 884.45 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9515992_1 CDM 361 RC 12035 HCPCS outpatient 931 698.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 792 85.07 999999999 726.18 884.45 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9515992_1 CDM 361 RC 12035 HCPCS outpatient 931 698.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 792 85.07 999999999 726.18 884.45 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9515992_1 CDM 361 RC 12035 HCPCS outpatient 931 698.25 MOLINA MCAID MOLINA MCAID 776.45 83.4 999999999 726.18 884.45 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9515992_1 CDM 361 RC 12035 HCPCS outpatient 931 698.25 MOLINA MCR ADV MOLINA MCR ADV 828.59 89 999999999 726.18 884.45 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9515992_1 CDM 361 RC 12035 HCPCS outpatient 931 698.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 828.59 89 999999999 726.18 884.45 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9515992_1 CDM 361 RC 12035 HCPCS outpatient 931 698.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 828.59 89 999999999 726.18 884.45 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9515992_1 CDM 361 RC 12035 HCPCS outpatient 931 698.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 837.9 90 999999999 726.18 884.45 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9515992_1 CDM 361 RC 12035 HCPCS outpatient 931 698.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 884.45 95 999999999 726.18 884.45 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9515992_1 CDM 361 RC 12035 HCPCS outpatient 931 698.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 884.45 95 999999999 726.18 884.45 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9515992_1 CDM 361 RC 12035 HCPCS outpatient 931 698.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 828.59 89 999999999 726.18 884.45 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9515992_1 CDM 361 RC 12035 HCPCS outpatient 931 698.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 819.28 88 999999999 726.18 884.45 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9515992_1 CDM 361 RC 12035 HCPCS outpatient 931 698.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 828.59 89 999999999 726.18 884.45 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9515992_2 CDM 361 RC 12035 HCPCS outpatient 931 698.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 837.9 999999999 726.18 884.45 case rate "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9515992_2 CDM 361 RC 12035 HCPCS outpatient 931 698.25 AETNA MCR ADV AETNA MCR ADV 726.18 78 999999999 726.18 884.45 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9515992_2 CDM 361 RC 12035 HCPCS outpatient 931 698.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 815.28 87.57 999999999 726.18 884.45 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9515992_2 CDM 361 RC 12035 HCPCS outpatient 931 698.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 792 85.07 999999999 726.18 884.45 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9515992_2 CDM 361 RC 12035 HCPCS outpatient 931 698.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 792 85.07 999999999 726.18 884.45 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9515992_2 CDM 361 RC 12035 HCPCS outpatient 931 698.25 MOLINA MCAID MOLINA MCAID 776.45 83.4 999999999 726.18 884.45 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9515992_2 CDM 361 RC 12035 HCPCS outpatient 931 698.25 MOLINA MCR ADV MOLINA MCR ADV 828.59 89 999999999 726.18 884.45 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9515992_2 CDM 361 RC 12035 HCPCS outpatient 931 698.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 828.59 89 999999999 726.18 884.45 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9515992_2 CDM 361 RC 12035 HCPCS outpatient 931 698.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 828.59 89 999999999 726.18 884.45 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9515992_2 CDM 361 RC 12035 HCPCS outpatient 931 698.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 837.9 90 999999999 726.18 884.45 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9515992_2 CDM 361 RC 12035 HCPCS outpatient 931 698.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 884.45 95 999999999 726.18 884.45 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9515992_2 CDM 361 RC 12035 HCPCS outpatient 931 698.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 884.45 95 999999999 726.18 884.45 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9515992_2 CDM 361 RC 12035 HCPCS outpatient 931 698.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 828.59 89 999999999 726.18 884.45 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9515992_2 CDM 361 RC 12035 HCPCS outpatient 931 698.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 819.28 88 999999999 726.18 884.45 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9515992_2 CDM 361 RC 12035 HCPCS outpatient 931 698.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 828.59 89 999999999 726.18 884.45 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 9515995_1 CDM 361 RC 12015 HCPCS outpatient 474 355.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 426.6 999999999 369.72 450.3 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 9515995_1 CDM 361 RC 12015 HCPCS outpatient 474 355.5 AETNA MCR ADV AETNA MCR ADV 369.72 78 999999999 369.72 450.3 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 9515995_1 CDM 361 RC 12015 HCPCS outpatient 474 355.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 415.08 87.57 999999999 369.72 450.3 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 9515995_1 CDM 361 RC 12015 HCPCS outpatient 474 355.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 403.23 85.07 999999999 369.72 450.3 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 9515995_1 CDM 361 RC 12015 HCPCS outpatient 474 355.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 403.23 85.07 999999999 369.72 450.3 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 9515995_1 CDM 361 RC 12015 HCPCS outpatient 474 355.5 MOLINA MCAID MOLINA MCAID 395.32 83.4 999999999 369.72 450.3 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 9515995_1 CDM 361 RC 12015 HCPCS outpatient 474 355.5 MOLINA MCR ADV MOLINA MCR ADV 421.86 89 999999999 369.72 450.3 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 9515995_1 CDM 361 RC 12015 HCPCS outpatient 474 355.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 421.86 89 999999999 369.72 450.3 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 9515995_1 CDM 361 RC 12015 HCPCS outpatient 474 355.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 421.86 89 999999999 369.72 450.3 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 9515995_1 CDM 361 RC 12015 HCPCS outpatient 474 355.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 426.6 90 999999999 369.72 450.3 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 9515995_1 CDM 361 RC 12015 HCPCS outpatient 474 355.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 450.3 95 999999999 369.72 450.3 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 9515995_1 CDM 361 RC 12015 HCPCS outpatient 474 355.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 450.3 95 999999999 369.72 450.3 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 9515995_1 CDM 361 RC 12015 HCPCS outpatient 474 355.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 421.86 89 999999999 369.72 450.3 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 9515995_1 CDM 361 RC 12015 HCPCS outpatient 474 355.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 417.12 88 999999999 369.72 450.3 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM" 9515995_1 CDM 361 RC 12015 HCPCS outpatient 474 355.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 421.86 89 999999999 369.72 450.3 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 9516007_1 CDM 361 RC 13121 HCPCS outpatient 1272 954 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1144.8 999999999 992.16 1208.4 case rate "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 9516007_1 CDM 361 RC 13121 HCPCS outpatient 1272 954 AETNA MCR ADV AETNA MCR ADV 992.16 78 999999999 992.16 1208.4 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 9516007_1 CDM 361 RC 13121 HCPCS outpatient 1272 954 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1113.89 87.57 999999999 992.16 1208.4 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 9516007_1 CDM 361 RC 13121 HCPCS outpatient 1272 954 COORDINATED CARE MCAID COORDINATED CARE MCAID 1082.09 85.07 999999999 992.16 1208.4 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 9516007_1 CDM 361 RC 13121 HCPCS outpatient 1272 954 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1082.09 85.07 999999999 992.16 1208.4 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 9516007_1 CDM 361 RC 13121 HCPCS outpatient 1272 954 MOLINA MCAID MOLINA MCAID 1060.85 83.4 999999999 992.16 1208.4 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 9516007_1 CDM 361 RC 13121 HCPCS outpatient 1272 954 MOLINA MCR ADV MOLINA MCR ADV 1132.08 89 999999999 992.16 1208.4 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 9516007_1 CDM 361 RC 13121 HCPCS outpatient 1272 954 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1132.08 89 999999999 992.16 1208.4 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 9516007_1 CDM 361 RC 13121 HCPCS outpatient 1272 954 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1132.08 89 999999999 992.16 1208.4 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 9516007_1 CDM 361 RC 13121 HCPCS outpatient 1272 954 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1144.8 90 999999999 992.16 1208.4 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 9516007_1 CDM 361 RC 13121 HCPCS outpatient 1272 954 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1208.4 95 999999999 992.16 1208.4 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 9516007_1 CDM 361 RC 13121 HCPCS outpatient 1272 954 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1208.4 95 999999999 992.16 1208.4 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 9516007_1 CDM 361 RC 13121 HCPCS outpatient 1272 954 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1132.08 89 999999999 992.16 1208.4 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 9516007_1 CDM 361 RC 13121 HCPCS outpatient 1272 954 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1119.36 88 999999999 992.16 1208.4 percent of total billed charges "REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM" 9516007_1 CDM 361 RC 13121 HCPCS outpatient 1272 954 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1132.08 89 999999999 992.16 1208.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 9516010_1 CDM 361 RC 12006 HCPCS outpatient 383 287.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 344.7 999999999 298.74 363.85 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 9516010_1 CDM 361 RC 12006 HCPCS outpatient 383 287.25 AETNA MCR ADV AETNA MCR ADV 298.74 78 999999999 298.74 363.85 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 9516010_1 CDM 361 RC 12006 HCPCS outpatient 383 287.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 335.39 87.57 999999999 298.74 363.85 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 9516010_1 CDM 361 RC 12006 HCPCS outpatient 383 287.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 325.82 85.07 999999999 298.74 363.85 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 9516010_1 CDM 361 RC 12006 HCPCS outpatient 383 287.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 325.82 85.07 999999999 298.74 363.85 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 9516010_1 CDM 361 RC 12006 HCPCS outpatient 383 287.25 MOLINA MCAID MOLINA MCAID 319.42 83.4 999999999 298.74 363.85 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 9516010_1 CDM 361 RC 12006 HCPCS outpatient 383 287.25 MOLINA MCR ADV MOLINA MCR ADV 340.87 89 999999999 298.74 363.85 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 9516010_1 CDM 361 RC 12006 HCPCS outpatient 383 287.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 340.87 89 999999999 298.74 363.85 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 9516010_1 CDM 361 RC 12006 HCPCS outpatient 383 287.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 340.87 89 999999999 298.74 363.85 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 9516010_1 CDM 361 RC 12006 HCPCS outpatient 383 287.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 344.7 90 999999999 298.74 363.85 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 9516010_1 CDM 361 RC 12006 HCPCS outpatient 383 287.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 363.85 95 999999999 298.74 363.85 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 9516010_1 CDM 361 RC 12006 HCPCS outpatient 383 287.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 363.85 95 999999999 298.74 363.85 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 9516010_1 CDM 361 RC 12006 HCPCS outpatient 383 287.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 340.87 89 999999999 298.74 363.85 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 9516010_1 CDM 361 RC 12006 HCPCS outpatient 383 287.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 337.04 88 999999999 298.74 363.85 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM" 9516010_1 CDM 361 RC 12006 HCPCS outpatient 383 287.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 340.87 89 999999999 298.74 363.85 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 9516011_1 CDM 361 RC 30903 HCPCS outpatient 564 423 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 507.6 999999999 439.92 535.8 case rate "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 9516011_1 CDM 361 RC 30903 HCPCS outpatient 564 423 AETNA MCR ADV AETNA MCR ADV 439.92 78 999999999 439.92 535.8 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 9516011_1 CDM 361 RC 30903 HCPCS outpatient 564 423 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 493.89 87.57 999999999 439.92 535.8 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 9516011_1 CDM 361 RC 30903 HCPCS outpatient 564 423 COORDINATED CARE MCAID COORDINATED CARE MCAID 479.79 85.07 999999999 439.92 535.8 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 9516011_1 CDM 361 RC 30903 HCPCS outpatient 564 423 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 479.79 85.07 999999999 439.92 535.8 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 9516011_1 CDM 361 RC 30903 HCPCS outpatient 564 423 MOLINA MCAID MOLINA MCAID 470.38 83.4 999999999 439.92 535.8 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 9516011_1 CDM 361 RC 30903 HCPCS outpatient 564 423 MOLINA MCR ADV MOLINA MCR ADV 501.96 89 999999999 439.92 535.8 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 9516011_1 CDM 361 RC 30903 HCPCS outpatient 564 423 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 501.96 89 999999999 439.92 535.8 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 9516011_1 CDM 361 RC 30903 HCPCS outpatient 564 423 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 501.96 89 999999999 439.92 535.8 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 9516011_1 CDM 361 RC 30903 HCPCS outpatient 564 423 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 507.6 90 999999999 439.92 535.8 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 9516011_1 CDM 361 RC 30903 HCPCS outpatient 564 423 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 535.8 95 999999999 439.92 535.8 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 9516011_1 CDM 361 RC 30903 HCPCS outpatient 564 423 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 535.8 95 999999999 439.92 535.8 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 9516011_1 CDM 361 RC 30903 HCPCS outpatient 564 423 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 501.96 89 999999999 439.92 535.8 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 9516011_1 CDM 361 RC 30903 HCPCS outpatient 564 423 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 496.32 88 999999999 439.92 535.8 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 9516011_1 CDM 361 RC 30903 HCPCS outpatient 564 423 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 501.96 89 999999999 439.92 535.8 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 9516011_2 CDM 361 RC 30903 HCPCS outpatient 700 525 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 630 999999999 546 665 case rate "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 9516011_2 CDM 361 RC 30903 HCPCS outpatient 700 525 AETNA MCR ADV AETNA MCR ADV 546 78 999999999 546 665 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 9516011_2 CDM 361 RC 30903 HCPCS outpatient 700 525 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 612.99 87.57 999999999 546 665 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 9516011_2 CDM 361 RC 30903 HCPCS outpatient 700 525 COORDINATED CARE MCAID COORDINATED CARE MCAID 595.49 85.07 999999999 546 665 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 9516011_2 CDM 361 RC 30903 HCPCS outpatient 700 525 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 595.49 85.07 999999999 546 665 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 9516011_2 CDM 361 RC 30903 HCPCS outpatient 700 525 MOLINA MCAID MOLINA MCAID 583.8 83.4 999999999 546 665 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 9516011_2 CDM 361 RC 30903 HCPCS outpatient 700 525 MOLINA MCR ADV MOLINA MCR ADV 623 89 999999999 546 665 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 9516011_2 CDM 361 RC 30903 HCPCS outpatient 700 525 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 623 89 999999999 546 665 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 9516011_2 CDM 361 RC 30903 HCPCS outpatient 700 525 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 623 89 999999999 546 665 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 9516011_2 CDM 361 RC 30903 HCPCS outpatient 700 525 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 630 90 999999999 546 665 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 9516011_2 CDM 361 RC 30903 HCPCS outpatient 700 525 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 665 95 999999999 546 665 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 9516011_2 CDM 361 RC 30903 HCPCS outpatient 700 525 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 665 95 999999999 546 665 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 9516011_2 CDM 361 RC 30903 HCPCS outpatient 700 525 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 623 89 999999999 546 665 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 9516011_2 CDM 361 RC 30903 HCPCS outpatient 700 525 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 616 88 999999999 546 665 percent of total billed charges "CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD" 9516011_2 CDM 361 RC 30903 HCPCS outpatient 700 525 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 623 89 999999999 546 665 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 9516015_1 CDM 361 RC 12041 HCPCS outpatient 690 517.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 621 999999999 538.2 655.5 case rate "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 9516015_1 CDM 361 RC 12041 HCPCS outpatient 690 517.5 AETNA MCR ADV AETNA MCR ADV 538.2 78 999999999 538.2 655.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 9516015_1 CDM 361 RC 12041 HCPCS outpatient 690 517.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 604.23 87.57 999999999 538.2 655.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 9516015_1 CDM 361 RC 12041 HCPCS outpatient 690 517.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 586.98 85.07 999999999 538.2 655.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 9516015_1 CDM 361 RC 12041 HCPCS outpatient 690 517.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 586.98 85.07 999999999 538.2 655.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 9516015_1 CDM 361 RC 12041 HCPCS outpatient 690 517.5 MOLINA MCAID MOLINA MCAID 575.46 83.4 999999999 538.2 655.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 9516015_1 CDM 361 RC 12041 HCPCS outpatient 690 517.5 MOLINA MCR ADV MOLINA MCR ADV 614.1 89 999999999 538.2 655.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 9516015_1 CDM 361 RC 12041 HCPCS outpatient 690 517.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 614.1 89 999999999 538.2 655.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 9516015_1 CDM 361 RC 12041 HCPCS outpatient 690 517.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 614.1 89 999999999 538.2 655.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 9516015_1 CDM 361 RC 12041 HCPCS outpatient 690 517.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 621 90 999999999 538.2 655.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 9516015_1 CDM 361 RC 12041 HCPCS outpatient 690 517.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 655.5 95 999999999 538.2 655.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 9516015_1 CDM 361 RC 12041 HCPCS outpatient 690 517.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 655.5 95 999999999 538.2 655.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 9516015_1 CDM 361 RC 12041 HCPCS outpatient 690 517.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 614.1 89 999999999 538.2 655.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 9516015_1 CDM 361 RC 12041 HCPCS outpatient 690 517.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 607.2 88 999999999 538.2 655.5 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS" 9516015_1 CDM 361 RC 12041 HCPCS outpatient 690 517.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 614.1 89 999999999 538.2 655.5 percent of total billed charges "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 9516023_1 CDM 361 RC 26725 HCPCS outpatient 252 189 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 226.8 999999999 196.56 239.4 case rate "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 9516023_1 CDM 361 RC 26725 HCPCS outpatient 252 189 AETNA MCR ADV AETNA MCR ADV 196.56 78 999999999 196.56 239.4 percent of total billed charges "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 9516023_1 CDM 361 RC 26725 HCPCS outpatient 252 189 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 220.68 87.57 999999999 196.56 239.4 percent of total billed charges "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 9516023_1 CDM 361 RC 26725 HCPCS outpatient 252 189 COORDINATED CARE MCAID COORDINATED CARE MCAID 214.38 85.07 999999999 196.56 239.4 percent of total billed charges "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 9516023_1 CDM 361 RC 26725 HCPCS outpatient 252 189 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 214.38 85.07 999999999 196.56 239.4 percent of total billed charges "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 9516023_1 CDM 361 RC 26725 HCPCS outpatient 252 189 MOLINA MCAID MOLINA MCAID 210.17 83.4 999999999 196.56 239.4 percent of total billed charges "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 9516023_1 CDM 361 RC 26725 HCPCS outpatient 252 189 MOLINA MCR ADV MOLINA MCR ADV 224.28 89 999999999 196.56 239.4 percent of total billed charges "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 9516023_1 CDM 361 RC 26725 HCPCS outpatient 252 189 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 224.28 89 999999999 196.56 239.4 percent of total billed charges "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 9516023_1 CDM 361 RC 26725 HCPCS outpatient 252 189 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 224.28 89 999999999 196.56 239.4 percent of total billed charges "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 9516023_1 CDM 361 RC 26725 HCPCS outpatient 252 189 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 226.8 90 999999999 196.56 239.4 percent of total billed charges "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 9516023_1 CDM 361 RC 26725 HCPCS outpatient 252 189 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 239.4 95 999999999 196.56 239.4 percent of total billed charges "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 9516023_1 CDM 361 RC 26725 HCPCS outpatient 252 189 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 239.4 95 999999999 196.56 239.4 percent of total billed charges "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 9516023_1 CDM 361 RC 26725 HCPCS outpatient 252 189 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 224.28 89 999999999 196.56 239.4 percent of total billed charges "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 9516023_1 CDM 361 RC 26725 HCPCS outpatient 252 189 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 221.76 88 999999999 196.56 239.4 percent of total billed charges "CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH" 9516023_1 CDM 361 RC 26725 HCPCS outpatient 252 189 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 224.28 89 999999999 196.56 239.4 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9516028_1 CDM 361 RC 12005 HCPCS outpatient 571 428.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 513.9 999999999 445.38 542.45 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9516028_1 CDM 361 RC 12005 HCPCS outpatient 571 428.25 AETNA MCR ADV AETNA MCR ADV 445.38 78 999999999 445.38 542.45 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9516028_1 CDM 361 RC 12005 HCPCS outpatient 571 428.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 500.02 87.57 999999999 445.38 542.45 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9516028_1 CDM 361 RC 12005 HCPCS outpatient 571 428.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 485.75 85.07 999999999 445.38 542.45 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9516028_1 CDM 361 RC 12005 HCPCS outpatient 571 428.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 485.75 85.07 999999999 445.38 542.45 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9516028_1 CDM 361 RC 12005 HCPCS outpatient 571 428.25 MOLINA MCAID MOLINA MCAID 476.21 83.4 999999999 445.38 542.45 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9516028_1 CDM 361 RC 12005 HCPCS outpatient 571 428.25 MOLINA MCR ADV MOLINA MCR ADV 508.19 89 999999999 445.38 542.45 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9516028_1 CDM 361 RC 12005 HCPCS outpatient 571 428.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 508.19 89 999999999 445.38 542.45 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9516028_1 CDM 361 RC 12005 HCPCS outpatient 571 428.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 508.19 89 999999999 445.38 542.45 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9516028_1 CDM 361 RC 12005 HCPCS outpatient 571 428.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 513.9 90 999999999 445.38 542.45 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9516028_1 CDM 361 RC 12005 HCPCS outpatient 571 428.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 542.45 95 999999999 445.38 542.45 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9516028_1 CDM 361 RC 12005 HCPCS outpatient 571 428.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 542.45 95 999999999 445.38 542.45 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9516028_1 CDM 361 RC 12005 HCPCS outpatient 571 428.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 508.19 89 999999999 445.38 542.45 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9516028_1 CDM 361 RC 12005 HCPCS outpatient 571 428.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 502.48 88 999999999 445.38 542.45 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9516028_1 CDM 361 RC 12005 HCPCS outpatient 571 428.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 508.19 89 999999999 445.38 542.45 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9516028_2 CDM 361 RC 12005 HCPCS outpatient 571 428.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 513.9 999999999 445.38 542.45 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9516028_2 CDM 361 RC 12005 HCPCS outpatient 571 428.25 AETNA MCR ADV AETNA MCR ADV 445.38 78 999999999 445.38 542.45 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9516028_2 CDM 361 RC 12005 HCPCS outpatient 571 428.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 500.02 87.57 999999999 445.38 542.45 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9516028_2 CDM 361 RC 12005 HCPCS outpatient 571 428.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 485.75 85.07 999999999 445.38 542.45 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9516028_2 CDM 361 RC 12005 HCPCS outpatient 571 428.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 485.75 85.07 999999999 445.38 542.45 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9516028_2 CDM 361 RC 12005 HCPCS outpatient 571 428.25 MOLINA MCAID MOLINA MCAID 476.21 83.4 999999999 445.38 542.45 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9516028_2 CDM 361 RC 12005 HCPCS outpatient 571 428.25 MOLINA MCR ADV MOLINA MCR ADV 508.19 89 999999999 445.38 542.45 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9516028_2 CDM 361 RC 12005 HCPCS outpatient 571 428.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 508.19 89 999999999 445.38 542.45 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9516028_2 CDM 361 RC 12005 HCPCS outpatient 571 428.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 508.19 89 999999999 445.38 542.45 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9516028_2 CDM 361 RC 12005 HCPCS outpatient 571 428.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 513.9 90 999999999 445.38 542.45 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9516028_2 CDM 361 RC 12005 HCPCS outpatient 571 428.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 542.45 95 999999999 445.38 542.45 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9516028_2 CDM 361 RC 12005 HCPCS outpatient 571 428.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 542.45 95 999999999 445.38 542.45 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9516028_2 CDM 361 RC 12005 HCPCS outpatient 571 428.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 508.19 89 999999999 445.38 542.45 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9516028_2 CDM 361 RC 12005 HCPCS outpatient 571 428.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 502.48 88 999999999 445.38 542.45 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM" 9516028_2 CDM 361 RC 12005 HCPCS outpatient 571 428.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 508.19 89 999999999 445.38 542.45 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516036_1 CDM 361 RC 12034 HCPCS outpatient 1158 868.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1042.2 999999999 903.24 1100.1 case rate "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516036_1 CDM 361 RC 12034 HCPCS outpatient 1158 868.5 AETNA MCR ADV AETNA MCR ADV 903.24 78 999999999 903.24 1100.1 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516036_1 CDM 361 RC 12034 HCPCS outpatient 1158 868.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1014.06 87.57 999999999 903.24 1100.1 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516036_1 CDM 361 RC 12034 HCPCS outpatient 1158 868.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 985.11 85.07 999999999 903.24 1100.1 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516036_1 CDM 361 RC 12034 HCPCS outpatient 1158 868.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 985.11 85.07 999999999 903.24 1100.1 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516036_1 CDM 361 RC 12034 HCPCS outpatient 1158 868.5 MOLINA MCAID MOLINA MCAID 965.77 83.4 999999999 903.24 1100.1 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516036_1 CDM 361 RC 12034 HCPCS outpatient 1158 868.5 MOLINA MCR ADV MOLINA MCR ADV 1030.62 89 999999999 903.24 1100.1 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516036_1 CDM 361 RC 12034 HCPCS outpatient 1158 868.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1030.62 89 999999999 903.24 1100.1 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516036_1 CDM 361 RC 12034 HCPCS outpatient 1158 868.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1030.62 89 999999999 903.24 1100.1 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516036_1 CDM 361 RC 12034 HCPCS outpatient 1158 868.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1042.2 90 999999999 903.24 1100.1 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516036_1 CDM 361 RC 12034 HCPCS outpatient 1158 868.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1100.1 95 999999999 903.24 1100.1 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516036_1 CDM 361 RC 12034 HCPCS outpatient 1158 868.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1100.1 95 999999999 903.24 1100.1 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516036_1 CDM 361 RC 12034 HCPCS outpatient 1158 868.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1030.62 89 999999999 903.24 1100.1 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516036_1 CDM 361 RC 12034 HCPCS outpatient 1158 868.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1019.04 88 999999999 903.24 1100.1 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516036_1 CDM 361 RC 12034 HCPCS outpatient 1158 868.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1030.62 89 999999999 903.24 1100.1 percent of total billed charges CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION 9516037_1 CDM 361 RC 27818 HCPCS outpatient 2800 2100 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 2520 999999999 2184 2660 case rate CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION 9516037_1 CDM 361 RC 27818 HCPCS outpatient 2800 2100 AETNA MCR ADV AETNA MCR ADV 2184 78 999999999 2184 2660 percent of total billed charges CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION 9516037_1 CDM 361 RC 27818 HCPCS outpatient 2800 2100 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 2451.96 87.57 999999999 2184 2660 percent of total billed charges CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION 9516037_1 CDM 361 RC 27818 HCPCS outpatient 2800 2100 COORDINATED CARE MCAID COORDINATED CARE MCAID 2381.96 85.07 999999999 2184 2660 percent of total billed charges CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION 9516037_1 CDM 361 RC 27818 HCPCS outpatient 2800 2100 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 2381.96 85.07 999999999 2184 2660 percent of total billed charges CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION 9516037_1 CDM 361 RC 27818 HCPCS outpatient 2800 2100 MOLINA MCAID MOLINA MCAID 2335.2 83.4 999999999 2184 2660 percent of total billed charges CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION 9516037_1 CDM 361 RC 27818 HCPCS outpatient 2800 2100 MOLINA MCR ADV MOLINA MCR ADV 2492 89 999999999 2184 2660 percent of total billed charges CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION 9516037_1 CDM 361 RC 27818 HCPCS outpatient 2800 2100 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 2492 89 999999999 2184 2660 percent of total billed charges CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION 9516037_1 CDM 361 RC 27818 HCPCS outpatient 2800 2100 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 2492 89 999999999 2184 2660 percent of total billed charges CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION 9516037_1 CDM 361 RC 27818 HCPCS outpatient 2800 2100 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 2520 90 999999999 2184 2660 percent of total billed charges CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION 9516037_1 CDM 361 RC 27818 HCPCS outpatient 2800 2100 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 2660 95 999999999 2184 2660 percent of total billed charges CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION 9516037_1 CDM 361 RC 27818 HCPCS outpatient 2800 2100 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 2660 95 999999999 2184 2660 percent of total billed charges CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION 9516037_1 CDM 361 RC 27818 HCPCS outpatient 2800 2100 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 2492 89 999999999 2184 2660 percent of total billed charges CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION 9516037_1 CDM 361 RC 27818 HCPCS outpatient 2800 2100 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 2464 88 999999999 2184 2660 percent of total billed charges CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION 9516037_1 CDM 361 RC 27818 HCPCS outpatient 2800 2100 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 2492 89 999999999 2184 2660 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 9516040_1 CDM 361 RC 12042 HCPCS outpatient 638 478.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 574.2 999999999 497.64 606.1 case rate "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 9516040_1 CDM 361 RC 12042 HCPCS outpatient 638 478.5 AETNA MCR ADV AETNA MCR ADV 497.64 78 999999999 497.64 606.1 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 9516040_1 CDM 361 RC 12042 HCPCS outpatient 638 478.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 558.7 87.57 999999999 497.64 606.1 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 9516040_1 CDM 361 RC 12042 HCPCS outpatient 638 478.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 542.75 85.07 999999999 497.64 606.1 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 9516040_1 CDM 361 RC 12042 HCPCS outpatient 638 478.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 542.75 85.07 999999999 497.64 606.1 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 9516040_1 CDM 361 RC 12042 HCPCS outpatient 638 478.5 MOLINA MCAID MOLINA MCAID 532.09 83.4 999999999 497.64 606.1 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 9516040_1 CDM 361 RC 12042 HCPCS outpatient 638 478.5 MOLINA MCR ADV MOLINA MCR ADV 567.82 89 999999999 497.64 606.1 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 9516040_1 CDM 361 RC 12042 HCPCS outpatient 638 478.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 567.82 89 999999999 497.64 606.1 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 9516040_1 CDM 361 RC 12042 HCPCS outpatient 638 478.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 567.82 89 999999999 497.64 606.1 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 9516040_1 CDM 361 RC 12042 HCPCS outpatient 638 478.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 574.2 90 999999999 497.64 606.1 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 9516040_1 CDM 361 RC 12042 HCPCS outpatient 638 478.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 606.1 95 999999999 497.64 606.1 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 9516040_1 CDM 361 RC 12042 HCPCS outpatient 638 478.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 606.1 95 999999999 497.64 606.1 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 9516040_1 CDM 361 RC 12042 HCPCS outpatient 638 478.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 567.82 89 999999999 497.64 606.1 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 9516040_1 CDM 361 RC 12042 HCPCS outpatient 638 478.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 561.44 88 999999999 497.64 606.1 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 9516040_1 CDM 361 RC 12042 HCPCS outpatient 638 478.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 567.82 89 999999999 497.64 606.1 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 9516040_2 CDM 361 RC 12042 HCPCS outpatient 638 478.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 574.2 999999999 497.64 606.1 case rate "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 9516040_2 CDM 361 RC 12042 HCPCS outpatient 638 478.5 AETNA MCR ADV AETNA MCR ADV 497.64 78 999999999 497.64 606.1 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 9516040_2 CDM 361 RC 12042 HCPCS outpatient 638 478.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 558.7 87.57 999999999 497.64 606.1 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 9516040_2 CDM 361 RC 12042 HCPCS outpatient 638 478.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 542.75 85.07 999999999 497.64 606.1 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 9516040_2 CDM 361 RC 12042 HCPCS outpatient 638 478.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 542.75 85.07 999999999 497.64 606.1 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 9516040_2 CDM 361 RC 12042 HCPCS outpatient 638 478.5 MOLINA MCAID MOLINA MCAID 532.09 83.4 999999999 497.64 606.1 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 9516040_2 CDM 361 RC 12042 HCPCS outpatient 638 478.5 MOLINA MCR ADV MOLINA MCR ADV 567.82 89 999999999 497.64 606.1 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 9516040_2 CDM 361 RC 12042 HCPCS outpatient 638 478.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 567.82 89 999999999 497.64 606.1 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 9516040_2 CDM 361 RC 12042 HCPCS outpatient 638 478.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 567.82 89 999999999 497.64 606.1 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 9516040_2 CDM 361 RC 12042 HCPCS outpatient 638 478.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 574.2 90 999999999 497.64 606.1 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 9516040_2 CDM 361 RC 12042 HCPCS outpatient 638 478.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 606.1 95 999999999 497.64 606.1 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 9516040_2 CDM 361 RC 12042 HCPCS outpatient 638 478.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 606.1 95 999999999 497.64 606.1 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 9516040_2 CDM 361 RC 12042 HCPCS outpatient 638 478.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 567.82 89 999999999 497.64 606.1 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 9516040_2 CDM 361 RC 12042 HCPCS outpatient 638 478.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 561.44 88 999999999 497.64 606.1 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM" 9516040_2 CDM 361 RC 12042 HCPCS outpatient 638 478.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 567.82 89 999999999 497.64 606.1 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 9516041_1 CDM 361 RC 65220 HCPCS outpatient 339 254.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 305.1 999999999 264.42 322.05 case rate "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 9516041_1 CDM 361 RC 65220 HCPCS outpatient 339 254.25 AETNA MCR ADV AETNA MCR ADV 264.42 78 999999999 264.42 322.05 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 9516041_1 CDM 361 RC 65220 HCPCS outpatient 339 254.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 296.86 87.57 999999999 264.42 322.05 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 9516041_1 CDM 361 RC 65220 HCPCS outpatient 339 254.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 288.39 85.07 999999999 264.42 322.05 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 9516041_1 CDM 361 RC 65220 HCPCS outpatient 339 254.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 288.39 85.07 999999999 264.42 322.05 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 9516041_1 CDM 361 RC 65220 HCPCS outpatient 339 254.25 MOLINA MCAID MOLINA MCAID 282.73 83.4 999999999 264.42 322.05 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 9516041_1 CDM 361 RC 65220 HCPCS outpatient 339 254.25 MOLINA MCR ADV MOLINA MCR ADV 301.71 89 999999999 264.42 322.05 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 9516041_1 CDM 361 RC 65220 HCPCS outpatient 339 254.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 301.71 89 999999999 264.42 322.05 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 9516041_1 CDM 361 RC 65220 HCPCS outpatient 339 254.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 301.71 89 999999999 264.42 322.05 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 9516041_1 CDM 361 RC 65220 HCPCS outpatient 339 254.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 305.1 90 999999999 264.42 322.05 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 9516041_1 CDM 361 RC 65220 HCPCS outpatient 339 254.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 322.05 95 999999999 264.42 322.05 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 9516041_1 CDM 361 RC 65220 HCPCS outpatient 339 254.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 322.05 95 999999999 264.42 322.05 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 9516041_1 CDM 361 RC 65220 HCPCS outpatient 339 254.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 301.71 89 999999999 264.42 322.05 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 9516041_1 CDM 361 RC 65220 HCPCS outpatient 339 254.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 298.32 88 999999999 264.42 322.05 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 9516041_1 CDM 361 RC 65220 HCPCS outpatient 339 254.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 301.71 89 999999999 264.42 322.05 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 9516041_2 CDM 361 RC 65220 HCPCS outpatient 339 254.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 305.1 999999999 264.42 322.05 case rate "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 9516041_2 CDM 361 RC 65220 HCPCS outpatient 339 254.25 AETNA MCR ADV AETNA MCR ADV 264.42 78 999999999 264.42 322.05 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 9516041_2 CDM 361 RC 65220 HCPCS outpatient 339 254.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 296.86 87.57 999999999 264.42 322.05 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 9516041_2 CDM 361 RC 65220 HCPCS outpatient 339 254.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 288.39 85.07 999999999 264.42 322.05 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 9516041_2 CDM 361 RC 65220 HCPCS outpatient 339 254.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 288.39 85.07 999999999 264.42 322.05 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 9516041_2 CDM 361 RC 65220 HCPCS outpatient 339 254.25 MOLINA MCAID MOLINA MCAID 282.73 83.4 999999999 264.42 322.05 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 9516041_2 CDM 361 RC 65220 HCPCS outpatient 339 254.25 MOLINA MCR ADV MOLINA MCR ADV 301.71 89 999999999 264.42 322.05 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 9516041_2 CDM 361 RC 65220 HCPCS outpatient 339 254.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 301.71 89 999999999 264.42 322.05 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 9516041_2 CDM 361 RC 65220 HCPCS outpatient 339 254.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 301.71 89 999999999 264.42 322.05 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 9516041_2 CDM 361 RC 65220 HCPCS outpatient 339 254.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 305.1 90 999999999 264.42 322.05 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 9516041_2 CDM 361 RC 65220 HCPCS outpatient 339 254.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 322.05 95 999999999 264.42 322.05 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 9516041_2 CDM 361 RC 65220 HCPCS outpatient 339 254.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 322.05 95 999999999 264.42 322.05 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 9516041_2 CDM 361 RC 65220 HCPCS outpatient 339 254.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 301.71 89 999999999 264.42 322.05 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 9516041_2 CDM 361 RC 65220 HCPCS outpatient 339 254.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 298.32 88 999999999 264.42 322.05 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP" 9516041_2 CDM 361 RC 65220 HCPCS outpatient 339 254.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 301.71 89 999999999 264.42 322.05 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 9516050_1 CDM 361 RC 12014 HCPCS outpatient 467 350.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 420.3 999999999 364.26 443.65 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 9516050_1 CDM 361 RC 12014 HCPCS outpatient 467 350.25 AETNA MCR ADV AETNA MCR ADV 364.26 78 999999999 364.26 443.65 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 9516050_1 CDM 361 RC 12014 HCPCS outpatient 467 350.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 408.95 87.57 999999999 364.26 443.65 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 9516050_1 CDM 361 RC 12014 HCPCS outpatient 467 350.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 397.28 85.07 999999999 364.26 443.65 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 9516050_1 CDM 361 RC 12014 HCPCS outpatient 467 350.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 397.28 85.07 999999999 364.26 443.65 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 9516050_1 CDM 361 RC 12014 HCPCS outpatient 467 350.25 MOLINA MCAID MOLINA MCAID 389.48 83.4 999999999 364.26 443.65 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 9516050_1 CDM 361 RC 12014 HCPCS outpatient 467 350.25 MOLINA MCR ADV MOLINA MCR ADV 415.63 89 999999999 364.26 443.65 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 9516050_1 CDM 361 RC 12014 HCPCS outpatient 467 350.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 415.63 89 999999999 364.26 443.65 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 9516050_1 CDM 361 RC 12014 HCPCS outpatient 467 350.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 415.63 89 999999999 364.26 443.65 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 9516050_1 CDM 361 RC 12014 HCPCS outpatient 467 350.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 420.3 90 999999999 364.26 443.65 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 9516050_1 CDM 361 RC 12014 HCPCS outpatient 467 350.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 443.65 95 999999999 364.26 443.65 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 9516050_1 CDM 361 RC 12014 HCPCS outpatient 467 350.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 443.65 95 999999999 364.26 443.65 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 9516050_1 CDM 361 RC 12014 HCPCS outpatient 467 350.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 415.63 89 999999999 364.26 443.65 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 9516050_1 CDM 361 RC 12014 HCPCS outpatient 467 350.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 410.96 88 999999999 364.26 443.65 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM" 9516050_1 CDM 361 RC 12014 HCPCS outpatient 467 350.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 415.63 89 999999999 364.26 443.65 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 9516051_1 CDM 361 RC 65205 HCPCS outpatient 560 420 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 504 999999999 436.8 532 case rate "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 9516051_1 CDM 361 RC 65205 HCPCS outpatient 560 420 AETNA MCR ADV AETNA MCR ADV 436.8 78 999999999 436.8 532 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 9516051_1 CDM 361 RC 65205 HCPCS outpatient 560 420 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 490.39 87.57 999999999 436.8 532 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 9516051_1 CDM 361 RC 65205 HCPCS outpatient 560 420 COORDINATED CARE MCAID COORDINATED CARE MCAID 476.39 85.07 999999999 436.8 532 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 9516051_1 CDM 361 RC 65205 HCPCS outpatient 560 420 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 476.39 85.07 999999999 436.8 532 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 9516051_1 CDM 361 RC 65205 HCPCS outpatient 560 420 MOLINA MCAID MOLINA MCAID 467.04 83.4 999999999 436.8 532 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 9516051_1 CDM 361 RC 65205 HCPCS outpatient 560 420 MOLINA MCR ADV MOLINA MCR ADV 498.4 89 999999999 436.8 532 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 9516051_1 CDM 361 RC 65205 HCPCS outpatient 560 420 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 498.4 89 999999999 436.8 532 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 9516051_1 CDM 361 RC 65205 HCPCS outpatient 560 420 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 498.4 89 999999999 436.8 532 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 9516051_1 CDM 361 RC 65205 HCPCS outpatient 560 420 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 504 90 999999999 436.8 532 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 9516051_1 CDM 361 RC 65205 HCPCS outpatient 560 420 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 532 95 999999999 436.8 532 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 9516051_1 CDM 361 RC 65205 HCPCS outpatient 560 420 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 532 95 999999999 436.8 532 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 9516051_1 CDM 361 RC 65205 HCPCS outpatient 560 420 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 498.4 89 999999999 436.8 532 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 9516051_1 CDM 361 RC 65205 HCPCS outpatient 560 420 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 492.8 88 999999999 436.8 532 percent of total billed charges "REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL" 9516051_1 CDM 361 RC 65205 HCPCS outpatient 560 420 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 498.4 89 999999999 436.8 532 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 9516054_1 CDM 361 RC 31500 HCPCS outpatient 752 564 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 676.8 999999999 586.56 714.4 case rate "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 9516054_1 CDM 361 RC 31500 HCPCS outpatient 752 564 AETNA MCR ADV AETNA MCR ADV 586.56 78 999999999 586.56 714.4 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 9516054_1 CDM 361 RC 31500 HCPCS outpatient 752 564 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 658.53 87.57 999999999 586.56 714.4 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 9516054_1 CDM 361 RC 31500 HCPCS outpatient 752 564 COORDINATED CARE MCAID COORDINATED CARE MCAID 639.73 85.07 999999999 586.56 714.4 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 9516054_1 CDM 361 RC 31500 HCPCS outpatient 752 564 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 639.73 85.07 999999999 586.56 714.4 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 9516054_1 CDM 361 RC 31500 HCPCS outpatient 752 564 MOLINA MCAID MOLINA MCAID 627.17 83.4 999999999 586.56 714.4 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 9516054_1 CDM 361 RC 31500 HCPCS outpatient 752 564 MOLINA MCR ADV MOLINA MCR ADV 669.28 89 999999999 586.56 714.4 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 9516054_1 CDM 361 RC 31500 HCPCS outpatient 752 564 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 669.28 89 999999999 586.56 714.4 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 9516054_1 CDM 361 RC 31500 HCPCS outpatient 752 564 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 669.28 89 999999999 586.56 714.4 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 9516054_1 CDM 361 RC 31500 HCPCS outpatient 752 564 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 676.8 90 999999999 586.56 714.4 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 9516054_1 CDM 361 RC 31500 HCPCS outpatient 752 564 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 714.4 95 999999999 586.56 714.4 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 9516054_1 CDM 361 RC 31500 HCPCS outpatient 752 564 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 714.4 95 999999999 586.56 714.4 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 9516054_1 CDM 361 RC 31500 HCPCS outpatient 752 564 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 669.28 89 999999999 586.56 714.4 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 9516054_1 CDM 361 RC 31500 HCPCS outpatient 752 564 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 661.76 88 999999999 586.56 714.4 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 9516054_1 CDM 361 RC 31500 HCPCS outpatient 752 564 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 669.28 89 999999999 586.56 714.4 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 9516054_2 CDM 361 RC 31500 HCPCS outpatient 752 564 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 676.8 999999999 586.56 714.4 case rate "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 9516054_2 CDM 361 RC 31500 HCPCS outpatient 752 564 AETNA MCR ADV AETNA MCR ADV 586.56 78 999999999 586.56 714.4 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 9516054_2 CDM 361 RC 31500 HCPCS outpatient 752 564 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 658.53 87.57 999999999 586.56 714.4 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 9516054_2 CDM 361 RC 31500 HCPCS outpatient 752 564 COORDINATED CARE MCAID COORDINATED CARE MCAID 639.73 85.07 999999999 586.56 714.4 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 9516054_2 CDM 361 RC 31500 HCPCS outpatient 752 564 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 639.73 85.07 999999999 586.56 714.4 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 9516054_2 CDM 361 RC 31500 HCPCS outpatient 752 564 MOLINA MCAID MOLINA MCAID 627.17 83.4 999999999 586.56 714.4 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 9516054_2 CDM 361 RC 31500 HCPCS outpatient 752 564 MOLINA MCR ADV MOLINA MCR ADV 669.28 89 999999999 586.56 714.4 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 9516054_2 CDM 361 RC 31500 HCPCS outpatient 752 564 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 669.28 89 999999999 586.56 714.4 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 9516054_2 CDM 361 RC 31500 HCPCS outpatient 752 564 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 669.28 89 999999999 586.56 714.4 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 9516054_2 CDM 361 RC 31500 HCPCS outpatient 752 564 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 676.8 90 999999999 586.56 714.4 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 9516054_2 CDM 361 RC 31500 HCPCS outpatient 752 564 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 714.4 95 999999999 586.56 714.4 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 9516054_2 CDM 361 RC 31500 HCPCS outpatient 752 564 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 714.4 95 999999999 586.56 714.4 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 9516054_2 CDM 361 RC 31500 HCPCS outpatient 752 564 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 669.28 89 999999999 586.56 714.4 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 9516054_2 CDM 361 RC 31500 HCPCS outpatient 752 564 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 661.76 88 999999999 586.56 714.4 percent of total billed charges "INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE" 9516054_2 CDM 361 RC 31500 HCPCS outpatient 752 564 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 669.28 89 999999999 586.56 714.4 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516057_1 CDM 361 RC 12052 HCPCS outpatient 573 429.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 515.7 999999999 446.94 544.35 case rate "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516057_1 CDM 361 RC 12052 HCPCS outpatient 573 429.75 AETNA MCR ADV AETNA MCR ADV 446.94 78 999999999 446.94 544.35 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516057_1 CDM 361 RC 12052 HCPCS outpatient 573 429.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 501.78 87.57 999999999 446.94 544.35 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516057_1 CDM 361 RC 12052 HCPCS outpatient 573 429.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 487.45 85.07 999999999 446.94 544.35 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516057_1 CDM 361 RC 12052 HCPCS outpatient 573 429.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 487.45 85.07 999999999 446.94 544.35 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516057_1 CDM 361 RC 12052 HCPCS outpatient 573 429.75 MOLINA MCAID MOLINA MCAID 477.88 83.4 999999999 446.94 544.35 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516057_1 CDM 361 RC 12052 HCPCS outpatient 573 429.75 MOLINA MCR ADV MOLINA MCR ADV 509.97 89 999999999 446.94 544.35 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516057_1 CDM 361 RC 12052 HCPCS outpatient 573 429.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 509.97 89 999999999 446.94 544.35 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516057_1 CDM 361 RC 12052 HCPCS outpatient 573 429.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 509.97 89 999999999 446.94 544.35 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516057_1 CDM 361 RC 12052 HCPCS outpatient 573 429.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 515.7 90 999999999 446.94 544.35 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516057_1 CDM 361 RC 12052 HCPCS outpatient 573 429.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 544.35 95 999999999 446.94 544.35 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516057_1 CDM 361 RC 12052 HCPCS outpatient 573 429.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 544.35 95 999999999 446.94 544.35 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516057_1 CDM 361 RC 12052 HCPCS outpatient 573 429.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 509.97 89 999999999 446.94 544.35 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516057_1 CDM 361 RC 12052 HCPCS outpatient 573 429.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 504.24 88 999999999 446.94 544.35 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516057_1 CDM 361 RC 12052 HCPCS outpatient 573 429.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 509.97 89 999999999 446.94 544.35 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516057_2 CDM 361 RC 12052 HCPCS outpatient 573 429.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 515.7 999999999 446.94 544.35 case rate "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516057_2 CDM 361 RC 12052 HCPCS outpatient 573 429.75 AETNA MCR ADV AETNA MCR ADV 446.94 78 999999999 446.94 544.35 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516057_2 CDM 361 RC 12052 HCPCS outpatient 573 429.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 501.78 87.57 999999999 446.94 544.35 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516057_2 CDM 361 RC 12052 HCPCS outpatient 573 429.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 487.45 85.07 999999999 446.94 544.35 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516057_2 CDM 361 RC 12052 HCPCS outpatient 573 429.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 487.45 85.07 999999999 446.94 544.35 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516057_2 CDM 361 RC 12052 HCPCS outpatient 573 429.75 MOLINA MCAID MOLINA MCAID 477.88 83.4 999999999 446.94 544.35 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516057_2 CDM 361 RC 12052 HCPCS outpatient 573 429.75 MOLINA MCR ADV MOLINA MCR ADV 509.97 89 999999999 446.94 544.35 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516057_2 CDM 361 RC 12052 HCPCS outpatient 573 429.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 509.97 89 999999999 446.94 544.35 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516057_2 CDM 361 RC 12052 HCPCS outpatient 573 429.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 509.97 89 999999999 446.94 544.35 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516057_2 CDM 361 RC 12052 HCPCS outpatient 573 429.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 515.7 90 999999999 446.94 544.35 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516057_2 CDM 361 RC 12052 HCPCS outpatient 573 429.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 544.35 95 999999999 446.94 544.35 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516057_2 CDM 361 RC 12052 HCPCS outpatient 573 429.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 544.35 95 999999999 446.94 544.35 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516057_2 CDM 361 RC 12052 HCPCS outpatient 573 429.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 509.97 89 999999999 446.94 544.35 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516057_2 CDM 361 RC 12052 HCPCS outpatient 573 429.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 504.24 88 999999999 446.94 544.35 percent of total billed charges "REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516057_2 CDM 361 RC 12052 HCPCS outpatient 573 429.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 509.97 89 999999999 446.94 544.35 percent of total billed charges "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 9516059_1 CDM 361 RC 69209 HCPCS outpatient 65 48.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 58.5 999999999 50.7 61.75 case rate "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 9516059_1 CDM 361 RC 69209 HCPCS outpatient 65 48.75 AETNA MCR ADV AETNA MCR ADV 50.7 78 999999999 50.7 61.75 percent of total billed charges "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 9516059_1 CDM 361 RC 69209 HCPCS outpatient 65 48.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 56.92 87.57 999999999 50.7 61.75 percent of total billed charges "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 9516059_1 CDM 361 RC 69209 HCPCS outpatient 65 48.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 55.3 85.07 999999999 50.7 61.75 percent of total billed charges "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 9516059_1 CDM 361 RC 69209 HCPCS outpatient 65 48.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 55.3 85.07 999999999 50.7 61.75 percent of total billed charges "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 9516059_1 CDM 361 RC 69209 HCPCS outpatient 65 48.75 MOLINA MCAID MOLINA MCAID 54.21 83.4 999999999 50.7 61.75 percent of total billed charges "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 9516059_1 CDM 361 RC 69209 HCPCS outpatient 65 48.75 MOLINA MCR ADV MOLINA MCR ADV 57.85 89 999999999 50.7 61.75 percent of total billed charges "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 9516059_1 CDM 361 RC 69209 HCPCS outpatient 65 48.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 57.85 89 999999999 50.7 61.75 percent of total billed charges "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 9516059_1 CDM 361 RC 69209 HCPCS outpatient 65 48.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 57.85 89 999999999 50.7 61.75 percent of total billed charges "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 9516059_1 CDM 361 RC 69209 HCPCS outpatient 65 48.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 58.5 90 999999999 50.7 61.75 percent of total billed charges "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 9516059_1 CDM 361 RC 69209 HCPCS outpatient 65 48.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 61.75 95 999999999 50.7 61.75 percent of total billed charges "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 9516059_1 CDM 361 RC 69209 HCPCS outpatient 65 48.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 61.75 95 999999999 50.7 61.75 percent of total billed charges "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 9516059_1 CDM 361 RC 69209 HCPCS outpatient 65 48.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 57.85 89 999999999 50.7 61.75 percent of total billed charges "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 9516059_1 CDM 361 RC 69209 HCPCS outpatient 65 48.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 57.2 88 999999999 50.7 61.75 percent of total billed charges "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 9516059_1 CDM 361 RC 69209 HCPCS outpatient 65 48.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 57.85 89 999999999 50.7 61.75 percent of total billed charges "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 9516059_2 CDM 361 RC 69209 HCPCS outpatient 65 48.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 58.5 999999999 50.7 61.75 case rate "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 9516059_2 CDM 361 RC 69209 HCPCS outpatient 65 48.75 AETNA MCR ADV AETNA MCR ADV 50.7 78 999999999 50.7 61.75 percent of total billed charges "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 9516059_2 CDM 361 RC 69209 HCPCS outpatient 65 48.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 56.92 87.57 999999999 50.7 61.75 percent of total billed charges "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 9516059_2 CDM 361 RC 69209 HCPCS outpatient 65 48.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 55.3 85.07 999999999 50.7 61.75 percent of total billed charges "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 9516059_2 CDM 361 RC 69209 HCPCS outpatient 65 48.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 55.3 85.07 999999999 50.7 61.75 percent of total billed charges "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 9516059_2 CDM 361 RC 69209 HCPCS outpatient 65 48.75 MOLINA MCAID MOLINA MCAID 54.21 83.4 999999999 50.7 61.75 percent of total billed charges "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 9516059_2 CDM 361 RC 69209 HCPCS outpatient 65 48.75 MOLINA MCR ADV MOLINA MCR ADV 57.85 89 999999999 50.7 61.75 percent of total billed charges "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 9516059_2 CDM 361 RC 69209 HCPCS outpatient 65 48.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 57.85 89 999999999 50.7 61.75 percent of total billed charges "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 9516059_2 CDM 361 RC 69209 HCPCS outpatient 65 48.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 57.85 89 999999999 50.7 61.75 percent of total billed charges "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 9516059_2 CDM 361 RC 69209 HCPCS outpatient 65 48.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 58.5 90 999999999 50.7 61.75 percent of total billed charges "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 9516059_2 CDM 361 RC 69209 HCPCS outpatient 65 48.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 61.75 95 999999999 50.7 61.75 percent of total billed charges "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 9516059_2 CDM 361 RC 69209 HCPCS outpatient 65 48.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 61.75 95 999999999 50.7 61.75 percent of total billed charges "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 9516059_2 CDM 361 RC 69209 HCPCS outpatient 65 48.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 57.85 89 999999999 50.7 61.75 percent of total billed charges "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 9516059_2 CDM 361 RC 69209 HCPCS outpatient 65 48.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 57.2 88 999999999 50.7 61.75 percent of total billed charges "REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL" 9516059_2 CDM 361 RC 69209 HCPCS outpatient 65 48.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 57.85 89 999999999 50.7 61.75 percent of total billed charges "CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516061_1 CDM 361 RC 26770 HCPCS outpatient 997 747.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 897.3 999999999 777.66 947.15 case rate "CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516061_1 CDM 361 RC 26770 HCPCS outpatient 997 747.75 AETNA MCR ADV AETNA MCR ADV 777.66 78 999999999 777.66 947.15 percent of total billed charges "CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516061_1 CDM 361 RC 26770 HCPCS outpatient 997 747.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 873.07 87.57 999999999 777.66 947.15 percent of total billed charges "CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516061_1 CDM 361 RC 26770 HCPCS outpatient 997 747.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 848.15 85.07 999999999 777.66 947.15 percent of total billed charges "CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516061_1 CDM 361 RC 26770 HCPCS outpatient 997 747.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 848.15 85.07 999999999 777.66 947.15 percent of total billed charges "CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516061_1 CDM 361 RC 26770 HCPCS outpatient 997 747.75 MOLINA MCAID MOLINA MCAID 831.5 83.4 999999999 777.66 947.15 percent of total billed charges "CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516061_1 CDM 361 RC 26770 HCPCS outpatient 997 747.75 MOLINA MCR ADV MOLINA MCR ADV 887.33 89 999999999 777.66 947.15 percent of total billed charges "CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516061_1 CDM 361 RC 26770 HCPCS outpatient 997 747.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 887.33 89 999999999 777.66 947.15 percent of total billed charges "CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516061_1 CDM 361 RC 26770 HCPCS outpatient 997 747.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 887.33 89 999999999 777.66 947.15 percent of total billed charges "CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516061_1 CDM 361 RC 26770 HCPCS outpatient 997 747.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 897.3 90 999999999 777.66 947.15 percent of total billed charges "CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516061_1 CDM 361 RC 26770 HCPCS outpatient 997 747.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 947.15 95 999999999 777.66 947.15 percent of total billed charges "CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516061_1 CDM 361 RC 26770 HCPCS outpatient 997 747.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 947.15 95 999999999 777.66 947.15 percent of total billed charges "CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516061_1 CDM 361 RC 26770 HCPCS outpatient 997 747.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 887.33 89 999999999 777.66 947.15 percent of total billed charges "CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516061_1 CDM 361 RC 26770 HCPCS outpatient 997 747.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 877.36 88 999999999 777.66 947.15 percent of total billed charges "CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516061_1 CDM 361 RC 26770 HCPCS outpatient 997 747.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 887.33 89 999999999 777.66 947.15 percent of total billed charges "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 9516064_1 CDM 361 RC 24640 HCPCS outpatient 280 210 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 252 999999999 218.4 266 case rate "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 9516064_1 CDM 361 RC 24640 HCPCS outpatient 280 210 AETNA MCR ADV AETNA MCR ADV 218.4 78 999999999 218.4 266 percent of total billed charges "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 9516064_1 CDM 361 RC 24640 HCPCS outpatient 280 210 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 245.2 87.57 999999999 218.4 266 percent of total billed charges "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 9516064_1 CDM 361 RC 24640 HCPCS outpatient 280 210 COORDINATED CARE MCAID COORDINATED CARE MCAID 238.2 85.07 999999999 218.4 266 percent of total billed charges "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 9516064_1 CDM 361 RC 24640 HCPCS outpatient 280 210 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 238.2 85.07 999999999 218.4 266 percent of total billed charges "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 9516064_1 CDM 361 RC 24640 HCPCS outpatient 280 210 MOLINA MCAID MOLINA MCAID 233.52 83.4 999999999 218.4 266 percent of total billed charges "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 9516064_1 CDM 361 RC 24640 HCPCS outpatient 280 210 MOLINA MCR ADV MOLINA MCR ADV 249.2 89 999999999 218.4 266 percent of total billed charges "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 9516064_1 CDM 361 RC 24640 HCPCS outpatient 280 210 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 249.2 89 999999999 218.4 266 percent of total billed charges "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 9516064_1 CDM 361 RC 24640 HCPCS outpatient 280 210 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 249.2 89 999999999 218.4 266 percent of total billed charges "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 9516064_1 CDM 361 RC 24640 HCPCS outpatient 280 210 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 252 90 999999999 218.4 266 percent of total billed charges "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 9516064_1 CDM 361 RC 24640 HCPCS outpatient 280 210 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 266 95 999999999 218.4 266 percent of total billed charges "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 9516064_1 CDM 361 RC 24640 HCPCS outpatient 280 210 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 266 95 999999999 218.4 266 percent of total billed charges "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 9516064_1 CDM 361 RC 24640 HCPCS outpatient 280 210 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 249.2 89 999999999 218.4 266 percent of total billed charges "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 9516064_1 CDM 361 RC 24640 HCPCS outpatient 280 210 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 246.4 88 999999999 218.4 266 percent of total billed charges "CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION" 9516064_1 CDM 361 RC 24640 HCPCS outpatient 280 210 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 249.2 89 999999999 218.4 266 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516073_1 CDM 361 RC 12004 HCPCS outpatient 390 292.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 351 999999999 304.2 370.5 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516073_1 CDM 361 RC 12004 HCPCS outpatient 390 292.5 AETNA MCR ADV AETNA MCR ADV 304.2 78 999999999 304.2 370.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516073_1 CDM 361 RC 12004 HCPCS outpatient 390 292.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 341.52 87.57 999999999 304.2 370.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516073_1 CDM 361 RC 12004 HCPCS outpatient 390 292.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 331.77 85.07 999999999 304.2 370.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516073_1 CDM 361 RC 12004 HCPCS outpatient 390 292.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 331.77 85.07 999999999 304.2 370.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516073_1 CDM 361 RC 12004 HCPCS outpatient 390 292.5 MOLINA MCAID MOLINA MCAID 325.26 83.4 999999999 304.2 370.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516073_1 CDM 361 RC 12004 HCPCS outpatient 390 292.5 MOLINA MCR ADV MOLINA MCR ADV 347.1 89 999999999 304.2 370.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516073_1 CDM 361 RC 12004 HCPCS outpatient 390 292.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 347.1 89 999999999 304.2 370.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516073_1 CDM 361 RC 12004 HCPCS outpatient 390 292.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 347.1 89 999999999 304.2 370.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516073_1 CDM 361 RC 12004 HCPCS outpatient 390 292.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 351 90 999999999 304.2 370.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516073_1 CDM 361 RC 12004 HCPCS outpatient 390 292.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 370.5 95 999999999 304.2 370.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516073_1 CDM 361 RC 12004 HCPCS outpatient 390 292.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 370.5 95 999999999 304.2 370.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516073_1 CDM 361 RC 12004 HCPCS outpatient 390 292.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 347.1 89 999999999 304.2 370.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516073_1 CDM 361 RC 12004 HCPCS outpatient 390 292.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 343.2 88 999999999 304.2 370.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516073_1 CDM 361 RC 12004 HCPCS outpatient 390 292.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 347.1 89 999999999 304.2 370.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516073_2 CDM 361 RC 12004 HCPCS outpatient 390 292.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 351 999999999 304.2 370.5 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516073_2 CDM 361 RC 12004 HCPCS outpatient 390 292.5 AETNA MCR ADV AETNA MCR ADV 304.2 78 999999999 304.2 370.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516073_2 CDM 361 RC 12004 HCPCS outpatient 390 292.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 341.52 87.57 999999999 304.2 370.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516073_2 CDM 361 RC 12004 HCPCS outpatient 390 292.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 331.77 85.07 999999999 304.2 370.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516073_2 CDM 361 RC 12004 HCPCS outpatient 390 292.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 331.77 85.07 999999999 304.2 370.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516073_2 CDM 361 RC 12004 HCPCS outpatient 390 292.5 MOLINA MCAID MOLINA MCAID 325.26 83.4 999999999 304.2 370.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516073_2 CDM 361 RC 12004 HCPCS outpatient 390 292.5 MOLINA MCR ADV MOLINA MCR ADV 347.1 89 999999999 304.2 370.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516073_2 CDM 361 RC 12004 HCPCS outpatient 390 292.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 347.1 89 999999999 304.2 370.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516073_2 CDM 361 RC 12004 HCPCS outpatient 390 292.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 347.1 89 999999999 304.2 370.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516073_2 CDM 361 RC 12004 HCPCS outpatient 390 292.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 351 90 999999999 304.2 370.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516073_2 CDM 361 RC 12004 HCPCS outpatient 390 292.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 370.5 95 999999999 304.2 370.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516073_2 CDM 361 RC 12004 HCPCS outpatient 390 292.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 370.5 95 999999999 304.2 370.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516073_2 CDM 361 RC 12004 HCPCS outpatient 390 292.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 347.1 89 999999999 304.2 370.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516073_2 CDM 361 RC 12004 HCPCS outpatient 390 292.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 343.2 88 999999999 304.2 370.5 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM" 9516073_2 CDM 361 RC 12004 HCPCS outpatient 390 292.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 347.1 89 999999999 304.2 370.5 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516075_1 CDM 361 RC 23650 HCPCS outpatient 934 700.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 840.6 999999999 728.52 887.3 case rate "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516075_1 CDM 361 RC 23650 HCPCS outpatient 934 700.5 AETNA MCR ADV AETNA MCR ADV 728.52 78 999999999 728.52 887.3 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516075_1 CDM 361 RC 23650 HCPCS outpatient 934 700.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 817.9 87.57 999999999 728.52 887.3 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516075_1 CDM 361 RC 23650 HCPCS outpatient 934 700.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 794.55 85.07 999999999 728.52 887.3 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516075_1 CDM 361 RC 23650 HCPCS outpatient 934 700.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 794.55 85.07 999999999 728.52 887.3 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516075_1 CDM 361 RC 23650 HCPCS outpatient 934 700.5 MOLINA MCAID MOLINA MCAID 778.96 83.4 999999999 728.52 887.3 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516075_1 CDM 361 RC 23650 HCPCS outpatient 934 700.5 MOLINA MCR ADV MOLINA MCR ADV 831.26 89 999999999 728.52 887.3 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516075_1 CDM 361 RC 23650 HCPCS outpatient 934 700.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 831.26 89 999999999 728.52 887.3 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516075_1 CDM 361 RC 23650 HCPCS outpatient 934 700.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 831.26 89 999999999 728.52 887.3 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516075_1 CDM 361 RC 23650 HCPCS outpatient 934 700.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 840.6 90 999999999 728.52 887.3 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516075_1 CDM 361 RC 23650 HCPCS outpatient 934 700.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 887.3 95 999999999 728.52 887.3 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516075_1 CDM 361 RC 23650 HCPCS outpatient 934 700.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 887.3 95 999999999 728.52 887.3 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516075_1 CDM 361 RC 23650 HCPCS outpatient 934 700.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 831.26 89 999999999 728.52 887.3 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516075_1 CDM 361 RC 23650 HCPCS outpatient 934 700.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 821.92 88 999999999 728.52 887.3 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516075_1 CDM 361 RC 23650 HCPCS outpatient 934 700.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 831.26 89 999999999 728.52 887.3 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516075_2 CDM 361 RC 23650 HCPCS outpatient 934 700.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 840.6 999999999 728.52 887.3 case rate "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516075_2 CDM 361 RC 23650 HCPCS outpatient 934 700.5 AETNA MCR ADV AETNA MCR ADV 728.52 78 999999999 728.52 887.3 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516075_2 CDM 361 RC 23650 HCPCS outpatient 934 700.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 817.9 87.57 999999999 728.52 887.3 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516075_2 CDM 361 RC 23650 HCPCS outpatient 934 700.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 794.55 85.07 999999999 728.52 887.3 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516075_2 CDM 361 RC 23650 HCPCS outpatient 934 700.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 794.55 85.07 999999999 728.52 887.3 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516075_2 CDM 361 RC 23650 HCPCS outpatient 934 700.5 MOLINA MCAID MOLINA MCAID 778.96 83.4 999999999 728.52 887.3 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516075_2 CDM 361 RC 23650 HCPCS outpatient 934 700.5 MOLINA MCR ADV MOLINA MCR ADV 831.26 89 999999999 728.52 887.3 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516075_2 CDM 361 RC 23650 HCPCS outpatient 934 700.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 831.26 89 999999999 728.52 887.3 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516075_2 CDM 361 RC 23650 HCPCS outpatient 934 700.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 831.26 89 999999999 728.52 887.3 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516075_2 CDM 361 RC 23650 HCPCS outpatient 934 700.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 840.6 90 999999999 728.52 887.3 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516075_2 CDM 361 RC 23650 HCPCS outpatient 934 700.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 887.3 95 999999999 728.52 887.3 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516075_2 CDM 361 RC 23650 HCPCS outpatient 934 700.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 887.3 95 999999999 728.52 887.3 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516075_2 CDM 361 RC 23650 HCPCS outpatient 934 700.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 831.26 89 999999999 728.52 887.3 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516075_2 CDM 361 RC 23650 HCPCS outpatient 934 700.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 821.92 88 999999999 728.52 887.3 percent of total billed charges "CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA" 9516075_2 CDM 361 RC 23650 HCPCS outpatient 934 700.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 831.26 89 999999999 728.52 887.3 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 9516078_1 CDM 361 RC 25605 HCPCS outpatient 1254 940.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1128.6 999999999 978.12 1191.3 case rate "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 9516078_1 CDM 361 RC 25605 HCPCS outpatient 1254 940.5 AETNA MCR ADV AETNA MCR ADV 978.12 78 999999999 978.12 1191.3 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 9516078_1 CDM 361 RC 25605 HCPCS outpatient 1254 940.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1098.13 87.57 999999999 978.12 1191.3 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 9516078_1 CDM 361 RC 25605 HCPCS outpatient 1254 940.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 1066.78 85.07 999999999 978.12 1191.3 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 9516078_1 CDM 361 RC 25605 HCPCS outpatient 1254 940.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1066.78 85.07 999999999 978.12 1191.3 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 9516078_1 CDM 361 RC 25605 HCPCS outpatient 1254 940.5 MOLINA MCAID MOLINA MCAID 1045.84 83.4 999999999 978.12 1191.3 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 9516078_1 CDM 361 RC 25605 HCPCS outpatient 1254 940.5 MOLINA MCR ADV MOLINA MCR ADV 1116.06 89 999999999 978.12 1191.3 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 9516078_1 CDM 361 RC 25605 HCPCS outpatient 1254 940.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1116.06 89 999999999 978.12 1191.3 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 9516078_1 CDM 361 RC 25605 HCPCS outpatient 1254 940.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1116.06 89 999999999 978.12 1191.3 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 9516078_1 CDM 361 RC 25605 HCPCS outpatient 1254 940.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1128.6 90 999999999 978.12 1191.3 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 9516078_1 CDM 361 RC 25605 HCPCS outpatient 1254 940.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1191.3 95 999999999 978.12 1191.3 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 9516078_1 CDM 361 RC 25605 HCPCS outpatient 1254 940.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1191.3 95 999999999 978.12 1191.3 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 9516078_1 CDM 361 RC 25605 HCPCS outpatient 1254 940.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1116.06 89 999999999 978.12 1191.3 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 9516078_1 CDM 361 RC 25605 HCPCS outpatient 1254 940.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1103.52 88 999999999 978.12 1191.3 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 9516078_1 CDM 361 RC 25605 HCPCS outpatient 1254 940.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1116.06 89 999999999 978.12 1191.3 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 9516078_2 CDM 361 RC 25605 HCPCS outpatient 1254 940.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1128.6 999999999 978.12 1191.3 case rate "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 9516078_2 CDM 361 RC 25605 HCPCS outpatient 1254 940.5 AETNA MCR ADV AETNA MCR ADV 978.12 78 999999999 978.12 1191.3 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 9516078_2 CDM 361 RC 25605 HCPCS outpatient 1254 940.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1098.13 87.57 999999999 978.12 1191.3 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 9516078_2 CDM 361 RC 25605 HCPCS outpatient 1254 940.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 1066.78 85.07 999999999 978.12 1191.3 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 9516078_2 CDM 361 RC 25605 HCPCS outpatient 1254 940.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1066.78 85.07 999999999 978.12 1191.3 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 9516078_2 CDM 361 RC 25605 HCPCS outpatient 1254 940.5 MOLINA MCAID MOLINA MCAID 1045.84 83.4 999999999 978.12 1191.3 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 9516078_2 CDM 361 RC 25605 HCPCS outpatient 1254 940.5 MOLINA MCR ADV MOLINA MCR ADV 1116.06 89 999999999 978.12 1191.3 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 9516078_2 CDM 361 RC 25605 HCPCS outpatient 1254 940.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1116.06 89 999999999 978.12 1191.3 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 9516078_2 CDM 361 RC 25605 HCPCS outpatient 1254 940.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1116.06 89 999999999 978.12 1191.3 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 9516078_2 CDM 361 RC 25605 HCPCS outpatient 1254 940.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1128.6 90 999999999 978.12 1191.3 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 9516078_2 CDM 361 RC 25605 HCPCS outpatient 1254 940.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 1191.3 95 999999999 978.12 1191.3 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 9516078_2 CDM 361 RC 25605 HCPCS outpatient 1254 940.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 1191.3 95 999999999 978.12 1191.3 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 9516078_2 CDM 361 RC 25605 HCPCS outpatient 1254 940.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1116.06 89 999999999 978.12 1191.3 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 9516078_2 CDM 361 RC 25605 HCPCS outpatient 1254 940.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1103.52 88 999999999 978.12 1191.3 percent of total billed charges "CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION" 9516078_2 CDM 361 RC 25605 HCPCS outpatient 1254 940.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1116.06 89 999999999 978.12 1191.3 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516085_1 CDM 361 RC 12013 HCPCS outpatient 389 291.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 350.1 999999999 303.42 369.55 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516085_1 CDM 361 RC 12013 HCPCS outpatient 389 291.75 AETNA MCR ADV AETNA MCR ADV 303.42 78 999999999 303.42 369.55 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516085_1 CDM 361 RC 12013 HCPCS outpatient 389 291.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 340.65 87.57 999999999 303.42 369.55 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516085_1 CDM 361 RC 12013 HCPCS outpatient 389 291.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 330.92 85.07 999999999 303.42 369.55 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516085_1 CDM 361 RC 12013 HCPCS outpatient 389 291.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 330.92 85.07 999999999 303.42 369.55 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516085_1 CDM 361 RC 12013 HCPCS outpatient 389 291.75 MOLINA MCAID MOLINA MCAID 324.43 83.4 999999999 303.42 369.55 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516085_1 CDM 361 RC 12013 HCPCS outpatient 389 291.75 MOLINA MCR ADV MOLINA MCR ADV 346.21 89 999999999 303.42 369.55 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516085_1 CDM 361 RC 12013 HCPCS outpatient 389 291.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 346.21 89 999999999 303.42 369.55 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516085_1 CDM 361 RC 12013 HCPCS outpatient 389 291.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 346.21 89 999999999 303.42 369.55 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516085_1 CDM 361 RC 12013 HCPCS outpatient 389 291.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 350.1 90 999999999 303.42 369.55 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516085_1 CDM 361 RC 12013 HCPCS outpatient 389 291.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 369.55 95 999999999 303.42 369.55 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516085_1 CDM 361 RC 12013 HCPCS outpatient 389 291.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 369.55 95 999999999 303.42 369.55 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516085_1 CDM 361 RC 12013 HCPCS outpatient 389 291.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 346.21 89 999999999 303.42 369.55 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516085_1 CDM 361 RC 12013 HCPCS outpatient 389 291.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 342.32 88 999999999 303.42 369.55 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516085_1 CDM 361 RC 12013 HCPCS outpatient 389 291.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 346.21 89 999999999 303.42 369.55 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516085_2 CDM 361 RC 12013 HCPCS outpatient 389 291.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 350.1 999999999 303.42 369.55 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516085_2 CDM 361 RC 12013 HCPCS outpatient 389 291.75 AETNA MCR ADV AETNA MCR ADV 303.42 78 999999999 303.42 369.55 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516085_2 CDM 361 RC 12013 HCPCS outpatient 389 291.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 340.65 87.57 999999999 303.42 369.55 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516085_2 CDM 361 RC 12013 HCPCS outpatient 389 291.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 330.92 85.07 999999999 303.42 369.55 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516085_2 CDM 361 RC 12013 HCPCS outpatient 389 291.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 330.92 85.07 999999999 303.42 369.55 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516085_2 CDM 361 RC 12013 HCPCS outpatient 389 291.75 MOLINA MCAID MOLINA MCAID 324.43 83.4 999999999 303.42 369.55 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516085_2 CDM 361 RC 12013 HCPCS outpatient 389 291.75 MOLINA MCR ADV MOLINA MCR ADV 346.21 89 999999999 303.42 369.55 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516085_2 CDM 361 RC 12013 HCPCS outpatient 389 291.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 346.21 89 999999999 303.42 369.55 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516085_2 CDM 361 RC 12013 HCPCS outpatient 389 291.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 346.21 89 999999999 303.42 369.55 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516085_2 CDM 361 RC 12013 HCPCS outpatient 389 291.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 350.1 90 999999999 303.42 369.55 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516085_2 CDM 361 RC 12013 HCPCS outpatient 389 291.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 369.55 95 999999999 303.42 369.55 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516085_2 CDM 361 RC 12013 HCPCS outpatient 389 291.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 369.55 95 999999999 303.42 369.55 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516085_2 CDM 361 RC 12013 HCPCS outpatient 389 291.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 346.21 89 999999999 303.42 369.55 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516085_2 CDM 361 RC 12013 HCPCS outpatient 389 291.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 342.32 88 999999999 303.42 369.55 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM" 9516085_2 CDM 361 RC 12013 HCPCS outpatient 389 291.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 346.21 89 999999999 303.42 369.55 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9516089_1 CDM 361 RC 12002 HCPCS outpatient 361 270.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 324.9 999999999 281.58 342.95 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9516089_1 CDM 361 RC 12002 HCPCS outpatient 361 270.75 AETNA MCR ADV AETNA MCR ADV 281.58 78 999999999 281.58 342.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9516089_1 CDM 361 RC 12002 HCPCS outpatient 361 270.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 316.13 87.57 999999999 281.58 342.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9516089_1 CDM 361 RC 12002 HCPCS outpatient 361 270.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 307.1 85.07 999999999 281.58 342.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9516089_1 CDM 361 RC 12002 HCPCS outpatient 361 270.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 307.1 85.07 999999999 281.58 342.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9516089_1 CDM 361 RC 12002 HCPCS outpatient 361 270.75 MOLINA MCAID MOLINA MCAID 301.07 83.4 999999999 281.58 342.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9516089_1 CDM 361 RC 12002 HCPCS outpatient 361 270.75 MOLINA MCR ADV MOLINA MCR ADV 321.29 89 999999999 281.58 342.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9516089_1 CDM 361 RC 12002 HCPCS outpatient 361 270.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 321.29 89 999999999 281.58 342.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9516089_1 CDM 361 RC 12002 HCPCS outpatient 361 270.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 321.29 89 999999999 281.58 342.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9516089_1 CDM 361 RC 12002 HCPCS outpatient 361 270.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 324.9 90 999999999 281.58 342.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9516089_1 CDM 361 RC 12002 HCPCS outpatient 361 270.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 342.95 95 999999999 281.58 342.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9516089_1 CDM 361 RC 12002 HCPCS outpatient 361 270.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 342.95 95 999999999 281.58 342.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9516089_1 CDM 361 RC 12002 HCPCS outpatient 361 270.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 321.29 89 999999999 281.58 342.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9516089_1 CDM 361 RC 12002 HCPCS outpatient 361 270.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 317.68 88 999999999 281.58 342.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9516089_1 CDM 361 RC 12002 HCPCS outpatient 361 270.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 321.29 89 999999999 281.58 342.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9516089_2 CDM 361 RC 12002 HCPCS outpatient 361 270.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 324.9 999999999 281.58 342.95 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9516089_2 CDM 361 RC 12002 HCPCS outpatient 361 270.75 AETNA MCR ADV AETNA MCR ADV 281.58 78 999999999 281.58 342.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9516089_2 CDM 361 RC 12002 HCPCS outpatient 361 270.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 316.13 87.57 999999999 281.58 342.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9516089_2 CDM 361 RC 12002 HCPCS outpatient 361 270.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 307.1 85.07 999999999 281.58 342.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9516089_2 CDM 361 RC 12002 HCPCS outpatient 361 270.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 307.1 85.07 999999999 281.58 342.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9516089_2 CDM 361 RC 12002 HCPCS outpatient 361 270.75 MOLINA MCAID MOLINA MCAID 301.07 83.4 999999999 281.58 342.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9516089_2 CDM 361 RC 12002 HCPCS outpatient 361 270.75 MOLINA MCR ADV MOLINA MCR ADV 321.29 89 999999999 281.58 342.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9516089_2 CDM 361 RC 12002 HCPCS outpatient 361 270.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 321.29 89 999999999 281.58 342.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9516089_2 CDM 361 RC 12002 HCPCS outpatient 361 270.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 321.29 89 999999999 281.58 342.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9516089_2 CDM 361 RC 12002 HCPCS outpatient 361 270.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 324.9 90 999999999 281.58 342.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9516089_2 CDM 361 RC 12002 HCPCS outpatient 361 270.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 342.95 95 999999999 281.58 342.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9516089_2 CDM 361 RC 12002 HCPCS outpatient 361 270.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 342.95 95 999999999 281.58 342.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9516089_2 CDM 361 RC 12002 HCPCS outpatient 361 270.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 321.29 89 999999999 281.58 342.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9516089_2 CDM 361 RC 12002 HCPCS outpatient 361 270.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 317.68 88 999999999 281.58 342.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM" 9516089_2 CDM 361 RC 12002 HCPCS outpatient 361 270.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 321.29 89 999999999 281.58 342.95 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 9516090_1 CDM 361 RC 12011 HCPCS outpatient 326 244.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 293.4 999999999 254.28 309.7 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 9516090_1 CDM 361 RC 12011 HCPCS outpatient 326 244.5 AETNA MCR ADV AETNA MCR ADV 254.28 78 999999999 254.28 309.7 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 9516090_1 CDM 361 RC 12011 HCPCS outpatient 326 244.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 285.48 87.57 999999999 254.28 309.7 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 9516090_1 CDM 361 RC 12011 HCPCS outpatient 326 244.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 277.33 85.07 999999999 254.28 309.7 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 9516090_1 CDM 361 RC 12011 HCPCS outpatient 326 244.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 277.33 85.07 999999999 254.28 309.7 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 9516090_1 CDM 361 RC 12011 HCPCS outpatient 326 244.5 MOLINA MCAID MOLINA MCAID 271.88 83.4 999999999 254.28 309.7 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 9516090_1 CDM 361 RC 12011 HCPCS outpatient 326 244.5 MOLINA MCR ADV MOLINA MCR ADV 290.14 89 999999999 254.28 309.7 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 9516090_1 CDM 361 RC 12011 HCPCS outpatient 326 244.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 290.14 89 999999999 254.28 309.7 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 9516090_1 CDM 361 RC 12011 HCPCS outpatient 326 244.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 290.14 89 999999999 254.28 309.7 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 9516090_1 CDM 361 RC 12011 HCPCS outpatient 326 244.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 293.4 90 999999999 254.28 309.7 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 9516090_1 CDM 361 RC 12011 HCPCS outpatient 326 244.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 309.7 95 999999999 254.28 309.7 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 9516090_1 CDM 361 RC 12011 HCPCS outpatient 326 244.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 309.7 95 999999999 254.28 309.7 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 9516090_1 CDM 361 RC 12011 HCPCS outpatient 326 244.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 290.14 89 999999999 254.28 309.7 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 9516090_1 CDM 361 RC 12011 HCPCS outpatient 326 244.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 286.88 88 999999999 254.28 309.7 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 9516090_1 CDM 361 RC 12011 HCPCS outpatient 326 244.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 290.14 89 999999999 254.28 309.7 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 9516090_2 CDM 361 RC 12011 HCPCS outpatient 326 244.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 293.4 999999999 254.28 309.7 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 9516090_2 CDM 361 RC 12011 HCPCS outpatient 326 244.5 AETNA MCR ADV AETNA MCR ADV 254.28 78 999999999 254.28 309.7 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 9516090_2 CDM 361 RC 12011 HCPCS outpatient 326 244.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 285.48 87.57 999999999 254.28 309.7 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 9516090_2 CDM 361 RC 12011 HCPCS outpatient 326 244.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 277.33 85.07 999999999 254.28 309.7 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 9516090_2 CDM 361 RC 12011 HCPCS outpatient 326 244.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 277.33 85.07 999999999 254.28 309.7 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 9516090_2 CDM 361 RC 12011 HCPCS outpatient 326 244.5 MOLINA MCAID MOLINA MCAID 271.88 83.4 999999999 254.28 309.7 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 9516090_2 CDM 361 RC 12011 HCPCS outpatient 326 244.5 MOLINA MCR ADV MOLINA MCR ADV 290.14 89 999999999 254.28 309.7 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 9516090_2 CDM 361 RC 12011 HCPCS outpatient 326 244.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 290.14 89 999999999 254.28 309.7 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 9516090_2 CDM 361 RC 12011 HCPCS outpatient 326 244.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 290.14 89 999999999 254.28 309.7 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 9516090_2 CDM 361 RC 12011 HCPCS outpatient 326 244.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 293.4 90 999999999 254.28 309.7 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 9516090_2 CDM 361 RC 12011 HCPCS outpatient 326 244.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 309.7 95 999999999 254.28 309.7 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 9516090_2 CDM 361 RC 12011 HCPCS outpatient 326 244.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 309.7 95 999999999 254.28 309.7 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 9516090_2 CDM 361 RC 12011 HCPCS outpatient 326 244.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 290.14 89 999999999 254.28 309.7 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 9516090_2 CDM 361 RC 12011 HCPCS outpatient 326 244.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 286.88 88 999999999 254.28 309.7 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS" 9516090_2 CDM 361 RC 12011 HCPCS outpatient 326 244.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 290.14 89 999999999 254.28 309.7 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 9516095_1 CDM 361 RC 11200 HCPCS outpatient 200 150 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 180 999999999 156 190 case rate "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 9516095_1 CDM 361 RC 11200 HCPCS outpatient 200 150 AETNA MCR ADV AETNA MCR ADV 156 78 999999999 156 190 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 9516095_1 CDM 361 RC 11200 HCPCS outpatient 200 150 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 175.14 87.57 999999999 156 190 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 9516095_1 CDM 361 RC 11200 HCPCS outpatient 200 150 COORDINATED CARE MCAID COORDINATED CARE MCAID 170.14 85.07 999999999 156 190 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 9516095_1 CDM 361 RC 11200 HCPCS outpatient 200 150 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 170.14 85.07 999999999 156 190 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 9516095_1 CDM 361 RC 11200 HCPCS outpatient 200 150 MOLINA MCAID MOLINA MCAID 166.8 83.4 999999999 156 190 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 9516095_1 CDM 361 RC 11200 HCPCS outpatient 200 150 MOLINA MCR ADV MOLINA MCR ADV 178 89 999999999 156 190 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 9516095_1 CDM 361 RC 11200 HCPCS outpatient 200 150 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 178 89 999999999 156 190 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 9516095_1 CDM 361 RC 11200 HCPCS outpatient 200 150 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 178 89 999999999 156 190 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 9516095_1 CDM 361 RC 11200 HCPCS outpatient 200 150 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 180 90 999999999 156 190 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 9516095_1 CDM 361 RC 11200 HCPCS outpatient 200 150 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 190 95 999999999 156 190 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 9516095_1 CDM 361 RC 11200 HCPCS outpatient 200 150 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 190 95 999999999 156 190 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 9516095_1 CDM 361 RC 11200 HCPCS outpatient 200 150 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 178 89 999999999 156 190 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 9516095_1 CDM 361 RC 11200 HCPCS outpatient 200 150 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 176 88 999999999 156 190 percent of total billed charges "REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS" 9516095_1 CDM 361 RC 11200 HCPCS outpatient 200 150 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 178 89 999999999 156 190 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 9516118_1 CDM 761 RC 12001 HCPCS outpatient 296 222 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 266.4 999999999 230.88 281.2 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 9516118_1 CDM 761 RC 12001 HCPCS outpatient 296 222 AETNA MCR ADV AETNA MCR ADV 230.88 78 999999999 230.88 281.2 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 9516118_1 CDM 761 RC 12001 HCPCS outpatient 296 222 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 259.21 87.57 999999999 230.88 281.2 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 9516118_1 CDM 761 RC 12001 HCPCS outpatient 296 222 COORDINATED CARE MCAID COORDINATED CARE MCAID 251.81 85.07 999999999 230.88 281.2 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 9516118_1 CDM 761 RC 12001 HCPCS outpatient 296 222 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 251.81 85.07 999999999 230.88 281.2 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 9516118_1 CDM 761 RC 12001 HCPCS outpatient 296 222 MOLINA MCAID MOLINA MCAID 246.86 83.4 999999999 230.88 281.2 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 9516118_1 CDM 761 RC 12001 HCPCS outpatient 296 222 MOLINA MCR ADV MOLINA MCR ADV 263.44 89 999999999 230.88 281.2 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 9516118_1 CDM 761 RC 12001 HCPCS outpatient 296 222 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 263.44 89 999999999 230.88 281.2 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 9516118_1 CDM 761 RC 12001 HCPCS outpatient 296 222 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 263.44 89 999999999 230.88 281.2 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 9516118_1 CDM 761 RC 12001 HCPCS outpatient 296 222 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 266.4 90 999999999 230.88 281.2 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 9516118_1 CDM 761 RC 12001 HCPCS outpatient 296 222 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 281.2 95 999999999 230.88 281.2 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 9516118_1 CDM 761 RC 12001 HCPCS outpatient 296 222 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 281.2 95 999999999 230.88 281.2 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 9516118_1 CDM 761 RC 12001 HCPCS outpatient 296 222 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 263.44 89 999999999 230.88 281.2 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 9516118_1 CDM 761 RC 12001 HCPCS outpatient 296 222 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 260.48 88 999999999 230.88 281.2 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 9516118_1 CDM 761 RC 12001 HCPCS outpatient 296 222 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 263.44 89 999999999 230.88 281.2 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 9516118_2 CDM 761 RC 12001 HCPCS outpatient 296 222 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 266.4 999999999 230.88 281.2 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 9516118_2 CDM 761 RC 12001 HCPCS outpatient 296 222 AETNA MCR ADV AETNA MCR ADV 230.88 78 999999999 230.88 281.2 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 9516118_2 CDM 761 RC 12001 HCPCS outpatient 296 222 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 259.21 87.57 999999999 230.88 281.2 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 9516118_2 CDM 761 RC 12001 HCPCS outpatient 296 222 COORDINATED CARE MCAID COORDINATED CARE MCAID 251.81 85.07 999999999 230.88 281.2 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 9516118_2 CDM 761 RC 12001 HCPCS outpatient 296 222 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 251.81 85.07 999999999 230.88 281.2 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 9516118_2 CDM 761 RC 12001 HCPCS outpatient 296 222 MOLINA MCAID MOLINA MCAID 246.86 83.4 999999999 230.88 281.2 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 9516118_2 CDM 761 RC 12001 HCPCS outpatient 296 222 MOLINA MCR ADV MOLINA MCR ADV 263.44 89 999999999 230.88 281.2 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 9516118_2 CDM 761 RC 12001 HCPCS outpatient 296 222 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 263.44 89 999999999 230.88 281.2 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 9516118_2 CDM 761 RC 12001 HCPCS outpatient 296 222 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 263.44 89 999999999 230.88 281.2 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 9516118_2 CDM 761 RC 12001 HCPCS outpatient 296 222 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 266.4 90 999999999 230.88 281.2 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 9516118_2 CDM 761 RC 12001 HCPCS outpatient 296 222 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 281.2 95 999999999 230.88 281.2 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 9516118_2 CDM 761 RC 12001 HCPCS outpatient 296 222 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 281.2 95 999999999 230.88 281.2 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 9516118_2 CDM 761 RC 12001 HCPCS outpatient 296 222 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 263.44 89 999999999 230.88 281.2 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 9516118_2 CDM 761 RC 12001 HCPCS outpatient 296 222 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 260.48 88 999999999 230.88 281.2 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS" 9516118_2 CDM 761 RC 12001 HCPCS outpatient 296 222 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 263.44 89 999999999 230.88 281.2 percent of total billed charges "RADIOLOGIC EXAMINATION, MANDIBLE; PARTIAL, LESS THAN 4 VIEWS" 9516125_1 CDM 320 RC 70100 HCPCS outpatient 423 317.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 380.7 90 999999999 329.94 401.85 percent of total billed charges "RADIOLOGIC EXAMINATION, MANDIBLE; PARTIAL, LESS THAN 4 VIEWS" 9516125_1 CDM 320 RC 70100 HCPCS outpatient 423 317.25 AETNA MCR ADV AETNA MCR ADV 329.94 78 999999999 329.94 401.85 percent of total billed charges "RADIOLOGIC EXAMINATION, MANDIBLE; PARTIAL, LESS THAN 4 VIEWS" 9516125_1 CDM 320 RC 70100 HCPCS outpatient 423 317.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 370.42 87.57 999999999 329.94 401.85 percent of total billed charges "RADIOLOGIC EXAMINATION, MANDIBLE; PARTIAL, LESS THAN 4 VIEWS" 9516125_1 CDM 320 RC 70100 HCPCS outpatient 423 317.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 359.85 85.07 999999999 329.94 401.85 percent of total billed charges "RADIOLOGIC EXAMINATION, MANDIBLE; PARTIAL, LESS THAN 4 VIEWS" 9516125_1 CDM 320 RC 70100 HCPCS outpatient 423 317.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 359.85 85.07 999999999 329.94 401.85 percent of total billed charges "RADIOLOGIC EXAMINATION, MANDIBLE; PARTIAL, LESS THAN 4 VIEWS" 9516125_1 CDM 320 RC 70100 HCPCS outpatient 423 317.25 MOLINA MCAID MOLINA MCAID 352.78 83.4 999999999 329.94 401.85 percent of total billed charges "RADIOLOGIC EXAMINATION, MANDIBLE; PARTIAL, LESS THAN 4 VIEWS" 9516125_1 CDM 320 RC 70100 HCPCS outpatient 423 317.25 MOLINA MCR ADV MOLINA MCR ADV 376.47 89 999999999 329.94 401.85 percent of total billed charges "RADIOLOGIC EXAMINATION, MANDIBLE; PARTIAL, LESS THAN 4 VIEWS" 9516125_1 CDM 320 RC 70100 HCPCS outpatient 423 317.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 376.47 89 999999999 329.94 401.85 percent of total billed charges "RADIOLOGIC EXAMINATION, MANDIBLE; PARTIAL, LESS THAN 4 VIEWS" 9516125_1 CDM 320 RC 70100 HCPCS outpatient 423 317.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 376.47 89 999999999 329.94 401.85 percent of total billed charges "RADIOLOGIC EXAMINATION, MANDIBLE; PARTIAL, LESS THAN 4 VIEWS" 9516125_1 CDM 320 RC 70100 HCPCS outpatient 423 317.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 380.7 90 999999999 329.94 401.85 percent of total billed charges "RADIOLOGIC EXAMINATION, MANDIBLE; PARTIAL, LESS THAN 4 VIEWS" 9516125_1 CDM 320 RC 70100 HCPCS outpatient 423 317.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 401.85 95 999999999 329.94 401.85 percent of total billed charges "RADIOLOGIC EXAMINATION, MANDIBLE; PARTIAL, LESS THAN 4 VIEWS" 9516125_1 CDM 320 RC 70100 HCPCS outpatient 423 317.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 401.85 95 999999999 329.94 401.85 percent of total billed charges "RADIOLOGIC EXAMINATION, MANDIBLE; PARTIAL, LESS THAN 4 VIEWS" 9516125_1 CDM 320 RC 70100 HCPCS outpatient 423 317.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 376.47 89 999999999 329.94 401.85 percent of total billed charges "RADIOLOGIC EXAMINATION, MANDIBLE; PARTIAL, LESS THAN 4 VIEWS" 9516125_1 CDM 320 RC 70100 HCPCS outpatient 423 317.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 372.24 88 999999999 329.94 401.85 percent of total billed charges "RADIOLOGIC EXAMINATION, MANDIBLE; PARTIAL, LESS THAN 4 VIEWS" 9516125_1 CDM 320 RC 70100 HCPCS outpatient 423 317.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 376.47 89 999999999 329.94 401.85 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 9516340_1 CDM 361 RC 12017 HCPCS outpatient 357 267.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 321.3 999999999 278.46 339.15 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 9516340_1 CDM 361 RC 12017 HCPCS outpatient 357 267.75 AETNA MCR ADV AETNA MCR ADV 278.46 78 999999999 278.46 339.15 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 9516340_1 CDM 361 RC 12017 HCPCS outpatient 357 267.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 312.62 87.57 999999999 278.46 339.15 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 9516340_1 CDM 361 RC 12017 HCPCS outpatient 357 267.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 303.7 85.07 999999999 278.46 339.15 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 9516340_1 CDM 361 RC 12017 HCPCS outpatient 357 267.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 303.7 85.07 999999999 278.46 339.15 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 9516340_1 CDM 361 RC 12017 HCPCS outpatient 357 267.75 MOLINA MCAID MOLINA MCAID 297.74 83.4 999999999 278.46 339.15 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 9516340_1 CDM 361 RC 12017 HCPCS outpatient 357 267.75 MOLINA MCR ADV MOLINA MCR ADV 317.73 89 999999999 278.46 339.15 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 9516340_1 CDM 361 RC 12017 HCPCS outpatient 357 267.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 317.73 89 999999999 278.46 339.15 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 9516340_1 CDM 361 RC 12017 HCPCS outpatient 357 267.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 317.73 89 999999999 278.46 339.15 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 9516340_1 CDM 361 RC 12017 HCPCS outpatient 357 267.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 321.3 90 999999999 278.46 339.15 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 9516340_1 CDM 361 RC 12017 HCPCS outpatient 357 267.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 339.15 95 999999999 278.46 339.15 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 9516340_1 CDM 361 RC 12017 HCPCS outpatient 357 267.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 339.15 95 999999999 278.46 339.15 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 9516340_1 CDM 361 RC 12017 HCPCS outpatient 357 267.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 317.73 89 999999999 278.46 339.15 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 9516340_1 CDM 361 RC 12017 HCPCS outpatient 357 267.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 314.16 88 999999999 278.46 339.15 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM" 9516340_1 CDM 361 RC 12017 HCPCS outpatient 357 267.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 317.73 89 999999999 278.46 339.15 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 9516347_1 CDM 361 RC 64451 HCPCS outpatient 2220 1665 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 1998 999999999 1731.6 2109 case rate "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 9516347_1 CDM 361 RC 64451 HCPCS outpatient 2220 1665 AETNA MCR ADV AETNA MCR ADV 1731.6 78 999999999 1731.6 2109 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 9516347_1 CDM 361 RC 64451 HCPCS outpatient 2220 1665 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 1944.05 87.57 999999999 1731.6 2109 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 9516347_1 CDM 361 RC 64451 HCPCS outpatient 2220 1665 COORDINATED CARE MCAID COORDINATED CARE MCAID 1888.55 85.07 999999999 1731.6 2109 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 9516347_1 CDM 361 RC 64451 HCPCS outpatient 2220 1665 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 1888.55 85.07 999999999 1731.6 2109 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 9516347_1 CDM 361 RC 64451 HCPCS outpatient 2220 1665 MOLINA MCAID MOLINA MCAID 1851.48 83.4 999999999 1731.6 2109 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 9516347_1 CDM 361 RC 64451 HCPCS outpatient 2220 1665 MOLINA MCR ADV MOLINA MCR ADV 1975.8 89 999999999 1731.6 2109 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 9516347_1 CDM 361 RC 64451 HCPCS outpatient 2220 1665 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 1975.8 89 999999999 1731.6 2109 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 9516347_1 CDM 361 RC 64451 HCPCS outpatient 2220 1665 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 1975.8 89 999999999 1731.6 2109 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 9516347_1 CDM 361 RC 64451 HCPCS outpatient 2220 1665 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 1998 90 999999999 1731.6 2109 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 9516347_1 CDM 361 RC 64451 HCPCS outpatient 2220 1665 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 2109 95 999999999 1731.6 2109 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 9516347_1 CDM 361 RC 64451 HCPCS outpatient 2220 1665 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 2109 95 999999999 1731.6 2109 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 9516347_1 CDM 361 RC 64451 HCPCS outpatient 2220 1665 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 1975.8 89 999999999 1731.6 2109 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 9516347_1 CDM 361 RC 64451 HCPCS outpatient 2220 1665 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 1953.6 88 999999999 1731.6 2109 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 9516347_1 CDM 361 RC 64451 HCPCS outpatient 2220 1665 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 1975.8 89 999999999 1731.6 2109 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 9516347_50_1 CDM 361 RC 64451 HCPCS outpatient 3330 2497.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 2997 999999999 2597.4 3163.5 case rate "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 9516347_50_1 CDM 361 RC 64451 HCPCS outpatient 3330 2497.5 AETNA MCR ADV AETNA MCR ADV 50 2597.4 78 999999999 2597.4 3163.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 9516347_50_1 CDM 361 RC 64451 HCPCS outpatient 3330 2497.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 2916.08 87.57 999999999 2597.4 3163.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 9516347_50_1 CDM 361 RC 64451 HCPCS outpatient 3330 2497.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 2832.83 85.07 999999999 2597.4 3163.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 9516347_50_1 CDM 361 RC 64451 HCPCS outpatient 3330 2497.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 2832.83 85.07 999999999 2597.4 3163.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 9516347_50_1 CDM 361 RC 64451 HCPCS outpatient 3330 2497.5 MOLINA MCAID MOLINA MCAID 50 2777.22 83.4 999999999 2597.4 3163.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 9516347_50_1 CDM 361 RC 64451 HCPCS outpatient 3330 2497.5 MOLINA MCR ADV MOLINA MCR ADV 50 2963.7 89 999999999 2597.4 3163.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 9516347_50_1 CDM 361 RC 64451 HCPCS outpatient 3330 2497.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 2963.7 89 999999999 2597.4 3163.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 9516347_50_1 CDM 361 RC 64451 HCPCS outpatient 3330 2497.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 2963.7 89 999999999 2597.4 3163.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 9516347_50_1 CDM 361 RC 64451 HCPCS outpatient 3330 2497.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 2997 90 999999999 2597.4 3163.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 9516347_50_1 CDM 361 RC 64451 HCPCS outpatient 3330 2497.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 3163.5 95 999999999 2597.4 3163.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 9516347_50_1 CDM 361 RC 64451 HCPCS outpatient 3330 2497.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 3163.5 95 999999999 2597.4 3163.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 9516347_50_1 CDM 361 RC 64451 HCPCS outpatient 3330 2497.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 2963.7 89 999999999 2597.4 3163.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 9516347_50_1 CDM 361 RC 64451 HCPCS outpatient 3330 2497.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 2930.4 88 999999999 2597.4 3163.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)" 9516347_50_1 CDM 361 RC 64451 HCPCS outpatient 3330 2497.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 2963.7 89 999999999 2597.4 3163.5 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GENICULAR NERVE BRANCHES, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516348_1 CDM 361 RC 64454 HCPCS outpatient 2438 1828.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 2194.2 999999999 1901.64 2316.1 case rate "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GENICULAR NERVE BRANCHES, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516348_1 CDM 361 RC 64454 HCPCS outpatient 2438 1828.5 AETNA MCR ADV AETNA MCR ADV 1901.64 78 999999999 1901.64 2316.1 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GENICULAR NERVE BRANCHES, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516348_1 CDM 361 RC 64454 HCPCS outpatient 2438 1828.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 2134.96 87.57 999999999 1901.64 2316.1 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GENICULAR NERVE BRANCHES, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516348_1 CDM 361 RC 64454 HCPCS outpatient 2438 1828.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 2074.01 85.07 999999999 1901.64 2316.1 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GENICULAR NERVE BRANCHES, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516348_1 CDM 361 RC 64454 HCPCS outpatient 2438 1828.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 2074.01 85.07 999999999 1901.64 2316.1 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GENICULAR NERVE BRANCHES, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516348_1 CDM 361 RC 64454 HCPCS outpatient 2438 1828.5 MOLINA MCAID MOLINA MCAID 2033.29 83.4 999999999 1901.64 2316.1 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GENICULAR NERVE BRANCHES, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516348_1 CDM 361 RC 64454 HCPCS outpatient 2438 1828.5 MOLINA MCR ADV MOLINA MCR ADV 2169.82 89 999999999 1901.64 2316.1 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GENICULAR NERVE BRANCHES, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516348_1 CDM 361 RC 64454 HCPCS outpatient 2438 1828.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 2169.82 89 999999999 1901.64 2316.1 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GENICULAR NERVE BRANCHES, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516348_1 CDM 361 RC 64454 HCPCS outpatient 2438 1828.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 2169.82 89 999999999 1901.64 2316.1 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GENICULAR NERVE BRANCHES, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516348_1 CDM 361 RC 64454 HCPCS outpatient 2438 1828.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 2194.2 90 999999999 1901.64 2316.1 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GENICULAR NERVE BRANCHES, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516348_1 CDM 361 RC 64454 HCPCS outpatient 2438 1828.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 2316.1 95 999999999 1901.64 2316.1 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GENICULAR NERVE BRANCHES, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516348_1 CDM 361 RC 64454 HCPCS outpatient 2438 1828.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 2316.1 95 999999999 1901.64 2316.1 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GENICULAR NERVE BRANCHES, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516348_1 CDM 361 RC 64454 HCPCS outpatient 2438 1828.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 2169.82 89 999999999 1901.64 2316.1 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GENICULAR NERVE BRANCHES, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516348_1 CDM 361 RC 64454 HCPCS outpatient 2438 1828.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 2145.44 88 999999999 1901.64 2316.1 percent of total billed charges "INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GENICULAR NERVE BRANCHES, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516348_1 CDM 361 RC 64454 HCPCS outpatient 2438 1828.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 2169.82 89 999999999 1901.64 2316.1 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_1 CDM 361 RC 64624 HCPCS outpatient 3624 2718 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 3261.6 999999999 2826.72 3442.8 case rate "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_1 CDM 361 RC 64624 HCPCS outpatient 3624 2718 AETNA MCR ADV AETNA MCR ADV 2826.72 78 999999999 2826.72 3442.8 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_1 CDM 361 RC 64624 HCPCS outpatient 3624 2718 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 3173.54 87.57 999999999 2826.72 3442.8 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_1 CDM 361 RC 64624 HCPCS outpatient 3624 2718 COORDINATED CARE MCAID COORDINATED CARE MCAID 3082.94 85.07 999999999 2826.72 3442.8 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_1 CDM 361 RC 64624 HCPCS outpatient 3624 2718 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 3082.94 85.07 999999999 2826.72 3442.8 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_1 CDM 361 RC 64624 HCPCS outpatient 3624 2718 MOLINA MCAID MOLINA MCAID 3022.42 83.4 999999999 2826.72 3442.8 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_1 CDM 361 RC 64624 HCPCS outpatient 3624 2718 MOLINA MCR ADV MOLINA MCR ADV 3225.36 89 999999999 2826.72 3442.8 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_1 CDM 361 RC 64624 HCPCS outpatient 3624 2718 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 3225.36 89 999999999 2826.72 3442.8 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_1 CDM 361 RC 64624 HCPCS outpatient 3624 2718 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 3225.36 89 999999999 2826.72 3442.8 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_1 CDM 361 RC 64624 HCPCS outpatient 3624 2718 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 3261.6 90 999999999 2826.72 3442.8 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_1 CDM 361 RC 64624 HCPCS outpatient 3624 2718 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 3442.8 95 999999999 2826.72 3442.8 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_1 CDM 361 RC 64624 HCPCS outpatient 3624 2718 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 3442.8 95 999999999 2826.72 3442.8 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_1 CDM 361 RC 64624 HCPCS outpatient 3624 2718 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 3225.36 89 999999999 2826.72 3442.8 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_1 CDM 361 RC 64624 HCPCS outpatient 3624 2718 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 3189.12 88 999999999 2826.72 3442.8 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_1 CDM 361 RC 64624 HCPCS outpatient 3624 2718 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 3225.36 89 999999999 2826.72 3442.8 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_50 CDM 361 RC 64624 HCPCS inpatient 5046 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_50 CDM 361 RC 64624 HCPCS inpatient 5046 AETNA MCR ADV AETNA MCR ADV 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_50 CDM 361 RC 64624 HCPCS inpatient 5046 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_50 CDM 361 RC 64624 HCPCS inpatient 5046 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_50 CDM 361 RC 64624 HCPCS inpatient 5046 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_50 CDM 361 RC 64624 HCPCS inpatient 5046 MOLINA MCAID MOLINA MCAID 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_50 CDM 361 RC 64624 HCPCS inpatient 5046 MOLINA MCR ADV MOLINA MCR ADV 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_50 CDM 361 RC 64624 HCPCS inpatient 5046 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_50 CDM 361 RC 64624 HCPCS inpatient 5046 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_50 CDM 361 RC 64624 HCPCS inpatient 5046 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_50 CDM 361 RC 64624 HCPCS inpatient 5046 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_50 CDM 361 RC 64624 HCPCS inpatient 5046 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_50 CDM 361 RC 64624 HCPCS inpatient 5046 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_50 CDM 361 RC 64624 HCPCS inpatient 5046 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_50 CDM 361 RC 64624 HCPCS inpatient 5046 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 999999999 "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_50_1 CDM 361 RC 64624 HCPCS outpatient 5046 3784.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50 4541.4 999999999 3935.88 4793.7 case rate "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_50_1 CDM 361 RC 64624 HCPCS outpatient 5046 3784.5 AETNA MCR ADV AETNA MCR ADV 50 3935.88 78 999999999 3935.88 4793.7 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_50_1 CDM 361 RC 64624 HCPCS outpatient 5046 3784.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 50 4418.78 87.57 999999999 3935.88 4793.7 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_50_1 CDM 361 RC 64624 HCPCS outpatient 5046 3784.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 50 4292.63 85.07 999999999 3935.88 4793.7 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_50_1 CDM 361 RC 64624 HCPCS outpatient 5046 3784.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 50 4292.63 85.07 999999999 3935.88 4793.7 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_50_1 CDM 361 RC 64624 HCPCS outpatient 5046 3784.5 MOLINA MCAID MOLINA MCAID 50 4208.36 83.4 999999999 3935.88 4793.7 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_50_1 CDM 361 RC 64624 HCPCS outpatient 5046 3784.5 MOLINA MCR ADV MOLINA MCR ADV 50 4490.94 89 999999999 3935.88 4793.7 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_50_1 CDM 361 RC 64624 HCPCS outpatient 5046 3784.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 50 4490.94 89 999999999 3935.88 4793.7 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_50_1 CDM 361 RC 64624 HCPCS outpatient 5046 3784.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 50 4490.94 89 999999999 3935.88 4793.7 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_50_1 CDM 361 RC 64624 HCPCS outpatient 5046 3784.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 50 4541.4 90 999999999 3935.88 4793.7 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_50_1 CDM 361 RC 64624 HCPCS outpatient 5046 3784.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 50 4793.7 95 999999999 3935.88 4793.7 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_50_1 CDM 361 RC 64624 HCPCS outpatient 5046 3784.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 50 4793.7 95 999999999 3935.88 4793.7 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_50_1 CDM 361 RC 64624 HCPCS outpatient 5046 3784.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 50 4490.94 89 999999999 3935.88 4793.7 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_50_1 CDM 361 RC 64624 HCPCS outpatient 5046 3784.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 50 4440.48 88 999999999 3935.88 4793.7 percent of total billed charges "DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED" 9516349_50_1 CDM 361 RC 64624 HCPCS outpatient 5046 3784.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 50 4490.94 89 999999999 3935.88 4793.7 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 9516396_1 CDM 361 RC 12016 HCPCS outpatient 398 298.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 358.2 999999999 310.44 378.1 case rate "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 9516396_1 CDM 361 RC 12016 HCPCS outpatient 398 298.5 AETNA MCR ADV AETNA MCR ADV 310.44 78 999999999 310.44 378.1 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 9516396_1 CDM 361 RC 12016 HCPCS outpatient 398 298.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 348.53 87.57 999999999 310.44 378.1 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 9516396_1 CDM 361 RC 12016 HCPCS outpatient 398 298.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 338.58 85.07 999999999 310.44 378.1 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 9516396_1 CDM 361 RC 12016 HCPCS outpatient 398 298.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 338.58 85.07 999999999 310.44 378.1 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 9516396_1 CDM 361 RC 12016 HCPCS outpatient 398 298.5 MOLINA MCAID MOLINA MCAID 331.93 83.4 999999999 310.44 378.1 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 9516396_1 CDM 361 RC 12016 HCPCS outpatient 398 298.5 MOLINA MCR ADV MOLINA MCR ADV 354.22 89 999999999 310.44 378.1 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 9516396_1 CDM 361 RC 12016 HCPCS outpatient 398 298.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 354.22 89 999999999 310.44 378.1 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 9516396_1 CDM 361 RC 12016 HCPCS outpatient 398 298.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 354.22 89 999999999 310.44 378.1 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 9516396_1 CDM 361 RC 12016 HCPCS outpatient 398 298.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 358.2 90 999999999 310.44 378.1 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 9516396_1 CDM 361 RC 12016 HCPCS outpatient 398 298.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 378.1 95 999999999 310.44 378.1 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 9516396_1 CDM 361 RC 12016 HCPCS outpatient 398 298.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 378.1 95 999999999 310.44 378.1 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 9516396_1 CDM 361 RC 12016 HCPCS outpatient 398 298.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 354.22 89 999999999 310.44 378.1 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 9516396_1 CDM 361 RC 12016 HCPCS outpatient 398 298.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 350.24 88 999999999 310.44 378.1 percent of total billed charges "SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM" 9516396_1 CDM 361 RC 12016 HCPCS outpatient 398 298.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 354.22 89 999999999 310.44 378.1 percent of total billed charges "THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (EG, ATTENTION, MEMORY, REASONING, EXECUTIVE FUNCTION, PROBLEM SOLVING, AND/OR PRAGMATIC FUNCTIONING) AND COMPENSATORY STRATEGIES TO MANAGE THE PERFORMANCE OF AN ACTIVITY (EG, MANAGING TIME OR SCHEDULES, INITIATING, ORGANIZING, AND SEQUENCING TASKS), DIRECT (ONE-ON-ONE) PATIENT CONTACT; INITIAL 15 MINUTES" 9516401_1 CDM 440 RC 97129 HCPCS outpatient 85 63.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 76.5 90 999999999 66.3 80.75 percent of total billed charges "THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (EG, ATTENTION, MEMORY, REASONING, EXECUTIVE FUNCTION, PROBLEM SOLVING, AND/OR PRAGMATIC FUNCTIONING) AND COMPENSATORY STRATEGIES TO MANAGE THE PERFORMANCE OF AN ACTIVITY (EG, MANAGING TIME OR SCHEDULES, INITIATING, ORGANIZING, AND SEQUENCING TASKS), DIRECT (ONE-ON-ONE) PATIENT CONTACT; INITIAL 15 MINUTES" 9516401_1 CDM 440 RC 97129 HCPCS outpatient 85 63.75 AETNA MCR ADV AETNA MCR ADV 66.3 78 999999999 66.3 80.75 percent of total billed charges "THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (EG, ATTENTION, MEMORY, REASONING, EXECUTIVE FUNCTION, PROBLEM SOLVING, AND/OR PRAGMATIC FUNCTIONING) AND COMPENSATORY STRATEGIES TO MANAGE THE PERFORMANCE OF AN ACTIVITY (EG, MANAGING TIME OR SCHEDULES, INITIATING, ORGANIZING, AND SEQUENCING TASKS), DIRECT (ONE-ON-ONE) PATIENT CONTACT; INITIAL 15 MINUTES" 9516401_1 CDM 440 RC 97129 HCPCS outpatient 85 63.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 74.43 87.57 999999999 66.3 80.75 percent of total billed charges "THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (EG, ATTENTION, MEMORY, REASONING, EXECUTIVE FUNCTION, PROBLEM SOLVING, AND/OR PRAGMATIC FUNCTIONING) AND COMPENSATORY STRATEGIES TO MANAGE THE PERFORMANCE OF AN ACTIVITY (EG, MANAGING TIME OR SCHEDULES, INITIATING, ORGANIZING, AND SEQUENCING TASKS), DIRECT (ONE-ON-ONE) PATIENT CONTACT; INITIAL 15 MINUTES" 9516401_1 CDM 440 RC 97129 HCPCS outpatient 85 63.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 72.31 85.07 999999999 66.3 80.75 percent of total billed charges "THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (EG, ATTENTION, MEMORY, REASONING, EXECUTIVE FUNCTION, PROBLEM SOLVING, AND/OR PRAGMATIC FUNCTIONING) AND COMPENSATORY STRATEGIES TO MANAGE THE PERFORMANCE OF AN ACTIVITY (EG, MANAGING TIME OR SCHEDULES, INITIATING, ORGANIZING, AND SEQUENCING TASKS), DIRECT (ONE-ON-ONE) PATIENT CONTACT; INITIAL 15 MINUTES" 9516401_1 CDM 440 RC 97129 HCPCS outpatient 85 63.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 72.31 85.07 999999999 66.3 80.75 percent of total billed charges "THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (EG, ATTENTION, MEMORY, REASONING, EXECUTIVE FUNCTION, PROBLEM SOLVING, AND/OR PRAGMATIC FUNCTIONING) AND COMPENSATORY STRATEGIES TO MANAGE THE PERFORMANCE OF AN ACTIVITY (EG, MANAGING TIME OR SCHEDULES, INITIATING, ORGANIZING, AND SEQUENCING TASKS), DIRECT (ONE-ON-ONE) PATIENT CONTACT; INITIAL 15 MINUTES" 9516401_1 CDM 440 RC 97129 HCPCS outpatient 85 63.75 MOLINA MCAID MOLINA MCAID 70.89 83.4 999999999 66.3 80.75 percent of total billed charges "THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (EG, ATTENTION, MEMORY, REASONING, EXECUTIVE FUNCTION, PROBLEM SOLVING, AND/OR PRAGMATIC FUNCTIONING) AND COMPENSATORY STRATEGIES TO MANAGE THE PERFORMANCE OF AN ACTIVITY (EG, MANAGING TIME OR SCHEDULES, INITIATING, ORGANIZING, AND SEQUENCING TASKS), DIRECT (ONE-ON-ONE) PATIENT CONTACT; INITIAL 15 MINUTES" 9516401_1 CDM 440 RC 97129 HCPCS outpatient 85 63.75 MOLINA MCR ADV MOLINA MCR ADV 75.65 89 999999999 66.3 80.75 percent of total billed charges "THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (EG, ATTENTION, MEMORY, REASONING, EXECUTIVE FUNCTION, PROBLEM SOLVING, AND/OR PRAGMATIC FUNCTIONING) AND COMPENSATORY STRATEGIES TO MANAGE THE PERFORMANCE OF AN ACTIVITY (EG, MANAGING TIME OR SCHEDULES, INITIATING, ORGANIZING, AND SEQUENCING TASKS), DIRECT (ONE-ON-ONE) PATIENT CONTACT; INITIAL 15 MINUTES" 9516401_1 CDM 440 RC 97129 HCPCS outpatient 85 63.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 75.65 89 999999999 66.3 80.75 percent of total billed charges "THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (EG, ATTENTION, MEMORY, REASONING, EXECUTIVE FUNCTION, PROBLEM SOLVING, AND/OR PRAGMATIC FUNCTIONING) AND COMPENSATORY STRATEGIES TO MANAGE THE PERFORMANCE OF AN ACTIVITY (EG, MANAGING TIME OR SCHEDULES, INITIATING, ORGANIZING, AND SEQUENCING TASKS), DIRECT (ONE-ON-ONE) PATIENT CONTACT; INITIAL 15 MINUTES" 9516401_1 CDM 440 RC 97129 HCPCS outpatient 85 63.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 75.65 89 999999999 66.3 80.75 percent of total billed charges "THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (EG, ATTENTION, MEMORY, REASONING, EXECUTIVE FUNCTION, PROBLEM SOLVING, AND/OR PRAGMATIC FUNCTIONING) AND COMPENSATORY STRATEGIES TO MANAGE THE PERFORMANCE OF AN ACTIVITY (EG, MANAGING TIME OR SCHEDULES, INITIATING, ORGANIZING, AND SEQUENCING TASKS), DIRECT (ONE-ON-ONE) PATIENT CONTACT; INITIAL 15 MINUTES" 9516401_1 CDM 440 RC 97129 HCPCS outpatient 85 63.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 76.5 90 999999999 66.3 80.75 percent of total billed charges "THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (EG, ATTENTION, MEMORY, REASONING, EXECUTIVE FUNCTION, PROBLEM SOLVING, AND/OR PRAGMATIC FUNCTIONING) AND COMPENSATORY STRATEGIES TO MANAGE THE PERFORMANCE OF AN ACTIVITY (EG, MANAGING TIME OR SCHEDULES, INITIATING, ORGANIZING, AND SEQUENCING TASKS), DIRECT (ONE-ON-ONE) PATIENT CONTACT; INITIAL 15 MINUTES" 9516401_1 CDM 440 RC 97129 HCPCS outpatient 85 63.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 80.75 95 999999999 66.3 80.75 percent of total billed charges "THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (EG, ATTENTION, MEMORY, REASONING, EXECUTIVE FUNCTION, PROBLEM SOLVING, AND/OR PRAGMATIC FUNCTIONING) AND COMPENSATORY STRATEGIES TO MANAGE THE PERFORMANCE OF AN ACTIVITY (EG, MANAGING TIME OR SCHEDULES, INITIATING, ORGANIZING, AND SEQUENCING TASKS), DIRECT (ONE-ON-ONE) PATIENT CONTACT; INITIAL 15 MINUTES" 9516401_1 CDM 440 RC 97129 HCPCS outpatient 85 63.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 80.75 95 999999999 66.3 80.75 percent of total billed charges "THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (EG, ATTENTION, MEMORY, REASONING, EXECUTIVE FUNCTION, PROBLEM SOLVING, AND/OR PRAGMATIC FUNCTIONING) AND COMPENSATORY STRATEGIES TO MANAGE THE PERFORMANCE OF AN ACTIVITY (EG, MANAGING TIME OR SCHEDULES, INITIATING, ORGANIZING, AND SEQUENCING TASKS), DIRECT (ONE-ON-ONE) PATIENT CONTACT; INITIAL 15 MINUTES" 9516401_1 CDM 440 RC 97129 HCPCS outpatient 85 63.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 75.65 89 999999999 66.3 80.75 percent of total billed charges "THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (EG, ATTENTION, MEMORY, REASONING, EXECUTIVE FUNCTION, PROBLEM SOLVING, AND/OR PRAGMATIC FUNCTIONING) AND COMPENSATORY STRATEGIES TO MANAGE THE PERFORMANCE OF AN ACTIVITY (EG, MANAGING TIME OR SCHEDULES, INITIATING, ORGANIZING, AND SEQUENCING TASKS), DIRECT (ONE-ON-ONE) PATIENT CONTACT; INITIAL 15 MINUTES" 9516401_1 CDM 440 RC 97129 HCPCS outpatient 85 63.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 74.8 88 999999999 66.3 80.75 percent of total billed charges "THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (EG, ATTENTION, MEMORY, REASONING, EXECUTIVE FUNCTION, PROBLEM SOLVING, AND/OR PRAGMATIC FUNCTIONING) AND COMPENSATORY STRATEGIES TO MANAGE THE PERFORMANCE OF AN ACTIVITY (EG, MANAGING TIME OR SCHEDULES, INITIATING, ORGANIZING, AND SEQUENCING TASKS), DIRECT (ONE-ON-ONE) PATIENT CONTACT; INITIAL 15 MINUTES" 9516401_1 CDM 440 RC 97129 HCPCS outpatient 85 63.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 75.65 89 999999999 66.3 80.75 percent of total billed charges "THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (EG, ATTENTION, MEMORY, REASONING, EXECUTIVE FUNCTION, PROBLEM SOLVING, AND/OR PRAGMATIC FUNCTIONING) AND COMPENSATORY STRATEGIES TO MANAGE THE PERFORMANCE OF AN ACTIVITY (EG, MANAGING TIME OR SCHEDULES, INITIATING, ORGANIZING, AND SEQUENCING TASKS), DIRECT (ONE-ON-ONE) PATIENT CONTACT; EACH ADDITIONAL 15 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9516402_1 CDM 430 RC 97130 HCPCS outpatient 65 48.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 58.5 90 999999999 50.7 61.75 percent of total billed charges "THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (EG, ATTENTION, MEMORY, REASONING, EXECUTIVE FUNCTION, PROBLEM SOLVING, AND/OR PRAGMATIC FUNCTIONING) AND COMPENSATORY STRATEGIES TO MANAGE THE PERFORMANCE OF AN ACTIVITY (EG, MANAGING TIME OR SCHEDULES, INITIATING, ORGANIZING, AND SEQUENCING TASKS), DIRECT (ONE-ON-ONE) PATIENT CONTACT; EACH ADDITIONAL 15 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9516402_1 CDM 430 RC 97130 HCPCS outpatient 65 48.75 AETNA MCR ADV AETNA MCR ADV 50.7 78 999999999 50.7 61.75 percent of total billed charges "THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (EG, ATTENTION, MEMORY, REASONING, EXECUTIVE FUNCTION, PROBLEM SOLVING, AND/OR PRAGMATIC FUNCTIONING) AND COMPENSATORY STRATEGIES TO MANAGE THE PERFORMANCE OF AN ACTIVITY (EG, MANAGING TIME OR SCHEDULES, INITIATING, ORGANIZING, AND SEQUENCING TASKS), DIRECT (ONE-ON-ONE) PATIENT CONTACT; EACH ADDITIONAL 15 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9516402_1 CDM 430 RC 97130 HCPCS outpatient 65 48.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 56.92 87.57 999999999 50.7 61.75 percent of total billed charges "THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (EG, ATTENTION, MEMORY, REASONING, EXECUTIVE FUNCTION, PROBLEM SOLVING, AND/OR PRAGMATIC FUNCTIONING) AND COMPENSATORY STRATEGIES TO MANAGE THE PERFORMANCE OF AN ACTIVITY (EG, MANAGING TIME OR SCHEDULES, INITIATING, ORGANIZING, AND SEQUENCING TASKS), DIRECT (ONE-ON-ONE) PATIENT CONTACT; EACH ADDITIONAL 15 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9516402_1 CDM 430 RC 97130 HCPCS outpatient 65 48.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 55.3 85.07 999999999 50.7 61.75 percent of total billed charges "THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (EG, ATTENTION, MEMORY, REASONING, EXECUTIVE FUNCTION, PROBLEM SOLVING, AND/OR PRAGMATIC FUNCTIONING) AND COMPENSATORY STRATEGIES TO MANAGE THE PERFORMANCE OF AN ACTIVITY (EG, MANAGING TIME OR SCHEDULES, INITIATING, ORGANIZING, AND SEQUENCING TASKS), DIRECT (ONE-ON-ONE) PATIENT CONTACT; EACH ADDITIONAL 15 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9516402_1 CDM 430 RC 97130 HCPCS outpatient 65 48.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 55.3 85.07 999999999 50.7 61.75 percent of total billed charges "THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (EG, ATTENTION, MEMORY, REASONING, EXECUTIVE FUNCTION, PROBLEM SOLVING, AND/OR PRAGMATIC FUNCTIONING) AND COMPENSATORY STRATEGIES TO MANAGE THE PERFORMANCE OF AN ACTIVITY (EG, MANAGING TIME OR SCHEDULES, INITIATING, ORGANIZING, AND SEQUENCING TASKS), DIRECT (ONE-ON-ONE) PATIENT CONTACT; EACH ADDITIONAL 15 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9516402_1 CDM 430 RC 97130 HCPCS outpatient 65 48.75 MOLINA MCAID MOLINA MCAID 54.21 83.4 999999999 50.7 61.75 percent of total billed charges "THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (EG, ATTENTION, MEMORY, REASONING, EXECUTIVE FUNCTION, PROBLEM SOLVING, AND/OR PRAGMATIC FUNCTIONING) AND COMPENSATORY STRATEGIES TO MANAGE THE PERFORMANCE OF AN ACTIVITY (EG, MANAGING TIME OR SCHEDULES, INITIATING, ORGANIZING, AND SEQUENCING TASKS), DIRECT (ONE-ON-ONE) PATIENT CONTACT; EACH ADDITIONAL 15 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9516402_1 CDM 430 RC 97130 HCPCS outpatient 65 48.75 MOLINA MCR ADV MOLINA MCR ADV 57.85 89 999999999 50.7 61.75 percent of total billed charges "THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (EG, ATTENTION, MEMORY, REASONING, EXECUTIVE FUNCTION, PROBLEM SOLVING, AND/OR PRAGMATIC FUNCTIONING) AND COMPENSATORY STRATEGIES TO MANAGE THE PERFORMANCE OF AN ACTIVITY (EG, MANAGING TIME OR SCHEDULES, INITIATING, ORGANIZING, AND SEQUENCING TASKS), DIRECT (ONE-ON-ONE) PATIENT CONTACT; EACH ADDITIONAL 15 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9516402_1 CDM 430 RC 97130 HCPCS outpatient 65 48.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 57.85 89 999999999 50.7 61.75 percent of total billed charges "THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (EG, ATTENTION, MEMORY, REASONING, EXECUTIVE FUNCTION, PROBLEM SOLVING, AND/OR PRAGMATIC FUNCTIONING) AND COMPENSATORY STRATEGIES TO MANAGE THE PERFORMANCE OF AN ACTIVITY (EG, MANAGING TIME OR SCHEDULES, INITIATING, ORGANIZING, AND SEQUENCING TASKS), DIRECT (ONE-ON-ONE) PATIENT CONTACT; EACH ADDITIONAL 15 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9516402_1 CDM 430 RC 97130 HCPCS outpatient 65 48.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 57.85 89 999999999 50.7 61.75 percent of total billed charges "THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (EG, ATTENTION, MEMORY, REASONING, EXECUTIVE FUNCTION, PROBLEM SOLVING, AND/OR PRAGMATIC FUNCTIONING) AND COMPENSATORY STRATEGIES TO MANAGE THE PERFORMANCE OF AN ACTIVITY (EG, MANAGING TIME OR SCHEDULES, INITIATING, ORGANIZING, AND SEQUENCING TASKS), DIRECT (ONE-ON-ONE) PATIENT CONTACT; EACH ADDITIONAL 15 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9516402_1 CDM 430 RC 97130 HCPCS outpatient 65 48.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 58.5 90 999999999 50.7 61.75 percent of total billed charges "THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (EG, ATTENTION, MEMORY, REASONING, EXECUTIVE FUNCTION, PROBLEM SOLVING, AND/OR PRAGMATIC FUNCTIONING) AND COMPENSATORY STRATEGIES TO MANAGE THE PERFORMANCE OF AN ACTIVITY (EG, MANAGING TIME OR SCHEDULES, INITIATING, ORGANIZING, AND SEQUENCING TASKS), DIRECT (ONE-ON-ONE) PATIENT CONTACT; EACH ADDITIONAL 15 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9516402_1 CDM 430 RC 97130 HCPCS outpatient 65 48.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 61.75 95 999999999 50.7 61.75 percent of total billed charges "THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (EG, ATTENTION, MEMORY, REASONING, EXECUTIVE FUNCTION, PROBLEM SOLVING, AND/OR PRAGMATIC FUNCTIONING) AND COMPENSATORY STRATEGIES TO MANAGE THE PERFORMANCE OF AN ACTIVITY (EG, MANAGING TIME OR SCHEDULES, INITIATING, ORGANIZING, AND SEQUENCING TASKS), DIRECT (ONE-ON-ONE) PATIENT CONTACT; EACH ADDITIONAL 15 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9516402_1 CDM 430 RC 97130 HCPCS outpatient 65 48.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 61.75 95 999999999 50.7 61.75 percent of total billed charges "THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (EG, ATTENTION, MEMORY, REASONING, EXECUTIVE FUNCTION, PROBLEM SOLVING, AND/OR PRAGMATIC FUNCTIONING) AND COMPENSATORY STRATEGIES TO MANAGE THE PERFORMANCE OF AN ACTIVITY (EG, MANAGING TIME OR SCHEDULES, INITIATING, ORGANIZING, AND SEQUENCING TASKS), DIRECT (ONE-ON-ONE) PATIENT CONTACT; EACH ADDITIONAL 15 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9516402_1 CDM 430 RC 97130 HCPCS outpatient 65 48.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 57.85 89 999999999 50.7 61.75 percent of total billed charges "THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (EG, ATTENTION, MEMORY, REASONING, EXECUTIVE FUNCTION, PROBLEM SOLVING, AND/OR PRAGMATIC FUNCTIONING) AND COMPENSATORY STRATEGIES TO MANAGE THE PERFORMANCE OF AN ACTIVITY (EG, MANAGING TIME OR SCHEDULES, INITIATING, ORGANIZING, AND SEQUENCING TASKS), DIRECT (ONE-ON-ONE) PATIENT CONTACT; EACH ADDITIONAL 15 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9516402_1 CDM 430 RC 97130 HCPCS outpatient 65 48.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 57.2 88 999999999 50.7 61.75 percent of total billed charges "THERAPEUTIC INTERVENTIONS THAT FOCUS ON COGNITIVE FUNCTION (EG, ATTENTION, MEMORY, REASONING, EXECUTIVE FUNCTION, PROBLEM SOLVING, AND/OR PRAGMATIC FUNCTIONING) AND COMPENSATORY STRATEGIES TO MANAGE THE PERFORMANCE OF AN ACTIVITY (EG, MANAGING TIME OR SCHEDULES, INITIATING, ORGANIZING, AND SEQUENCING TASKS), DIRECT (ONE-ON-ONE) PATIENT CONTACT; EACH ADDITIONAL 15 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)" 9516402_1 CDM 430 RC 97130 HCPCS outpatient 65 48.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 57.85 89 999999999 50.7 61.75 percent of total billed charges "INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG" 9516408_1 CDM 636 RC J3420 HCPCS outpatient 25 18.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 22.5 90 999999999 19.5 23.75 percent of total billed charges "INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG" 9516408_1 CDM 636 RC J3420 HCPCS outpatient 25 18.75 AETNA MCR ADV AETNA MCR ADV 19.5 78 999999999 19.5 23.75 percent of total billed charges "INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG" 9516408_1 CDM 636 RC J3420 HCPCS outpatient 25 18.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 21.89 87.57 999999999 19.5 23.75 percent of total billed charges "INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG" 9516408_1 CDM 636 RC J3420 HCPCS outpatient 25 18.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 21.27 85.07 999999999 19.5 23.75 percent of total billed charges "INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG" 9516408_1 CDM 636 RC J3420 HCPCS outpatient 25 18.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 21.27 85.07 999999999 19.5 23.75 percent of total billed charges "INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG" 9516408_1 CDM 636 RC J3420 HCPCS outpatient 25 18.75 MOLINA MCAID MOLINA MCAID 20.85 83.4 999999999 19.5 23.75 percent of total billed charges "INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG" 9516408_1 CDM 636 RC J3420 HCPCS outpatient 25 18.75 MOLINA MCR ADV MOLINA MCR ADV 22.25 89 999999999 19.5 23.75 percent of total billed charges "INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG" 9516408_1 CDM 636 RC J3420 HCPCS outpatient 25 18.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 22.25 89 999999999 19.5 23.75 percent of total billed charges "INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG" 9516408_1 CDM 636 RC J3420 HCPCS outpatient 25 18.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 22.25 89 999999999 19.5 23.75 percent of total billed charges "INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG" 9516408_1 CDM 636 RC J3420 HCPCS outpatient 25 18.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 22.5 90 999999999 19.5 23.75 percent of total billed charges "INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG" 9516408_1 CDM 636 RC J3420 HCPCS outpatient 25 18.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 23.75 95 999999999 19.5 23.75 percent of total billed charges "INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG" 9516408_1 CDM 636 RC J3420 HCPCS outpatient 25 18.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 23.75 95 999999999 19.5 23.75 percent of total billed charges "INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG" 9516408_1 CDM 636 RC J3420 HCPCS outpatient 25 18.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 22.25 89 999999999 19.5 23.75 percent of total billed charges "INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG" 9516408_1 CDM 636 RC J3420 HCPCS outpatient 25 18.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 22 88 999999999 19.5 23.75 percent of total billed charges "INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG" 9516408_1 CDM 636 RC J3420 HCPCS outpatient 25 18.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 22.25 89 999999999 19.5 23.75 percent of total billed charges "INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG" 9516413_1 CDM 636 RC J2765 HCPCS outpatient 30 22.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 27 90 999999999 23.4 28.5 percent of total billed charges "INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG" 9516413_1 CDM 636 RC J2765 HCPCS outpatient 30 22.5 AETNA MCR ADV AETNA MCR ADV 23.4 78 999999999 23.4 28.5 percent of total billed charges "INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG" 9516413_1 CDM 636 RC J2765 HCPCS outpatient 30 22.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 26.27 87.57 999999999 23.4 28.5 percent of total billed charges "INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG" 9516413_1 CDM 636 RC J2765 HCPCS outpatient 30 22.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 25.52 85.07 999999999 23.4 28.5 percent of total billed charges "INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG" 9516413_1 CDM 636 RC J2765 HCPCS outpatient 30 22.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 25.52 85.07 999999999 23.4 28.5 percent of total billed charges "INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG" 9516413_1 CDM 636 RC J2765 HCPCS outpatient 30 22.5 MOLINA MCAID MOLINA MCAID 25.02 83.4 999999999 23.4 28.5 percent of total billed charges "INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG" 9516413_1 CDM 636 RC J2765 HCPCS outpatient 30 22.5 MOLINA MCR ADV MOLINA MCR ADV 26.7 89 999999999 23.4 28.5 percent of total billed charges "INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG" 9516413_1 CDM 636 RC J2765 HCPCS outpatient 30 22.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 26.7 89 999999999 23.4 28.5 percent of total billed charges "INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG" 9516413_1 CDM 636 RC J2765 HCPCS outpatient 30 22.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 26.7 89 999999999 23.4 28.5 percent of total billed charges "INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG" 9516413_1 CDM 636 RC J2765 HCPCS outpatient 30 22.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 27 90 999999999 23.4 28.5 percent of total billed charges "INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG" 9516413_1 CDM 636 RC J2765 HCPCS outpatient 30 22.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 28.5 95 999999999 23.4 28.5 percent of total billed charges "INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG" 9516413_1 CDM 636 RC J2765 HCPCS outpatient 30 22.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 28.5 95 999999999 23.4 28.5 percent of total billed charges "INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG" 9516413_1 CDM 636 RC J2765 HCPCS outpatient 30 22.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 26.7 89 999999999 23.4 28.5 percent of total billed charges "INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG" 9516413_1 CDM 636 RC J2765 HCPCS outpatient 30 22.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 26.4 88 999999999 23.4 28.5 percent of total billed charges "INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG" 9516413_1 CDM 636 RC J2765 HCPCS outpatient 30 22.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 26.7 89 999999999 23.4 28.5 percent of total billed charges "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 9516414_1 CDM 636 RC J2405 HCPCS outpatient 7 5.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 6.3 90 999999999 5.46 6.65 percent of total billed charges "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 9516414_1 CDM 636 RC J2405 HCPCS outpatient 7 5.25 AETNA MCR ADV AETNA MCR ADV 5.46 78 999999999 5.46 6.65 percent of total billed charges "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 9516414_1 CDM 636 RC J2405 HCPCS outpatient 7 5.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 6.13 87.57 999999999 5.46 6.65 percent of total billed charges "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 9516414_1 CDM 636 RC J2405 HCPCS outpatient 7 5.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 5.95 85.07 999999999 5.46 6.65 percent of total billed charges "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 9516414_1 CDM 636 RC J2405 HCPCS outpatient 7 5.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 5.95 85.07 999999999 5.46 6.65 percent of total billed charges "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 9516414_1 CDM 636 RC J2405 HCPCS outpatient 7 5.25 MOLINA MCAID MOLINA MCAID 5.84 83.4 999999999 5.46 6.65 percent of total billed charges "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 9516414_1 CDM 636 RC J2405 HCPCS outpatient 7 5.25 MOLINA MCR ADV MOLINA MCR ADV 6.23 89 999999999 5.46 6.65 percent of total billed charges "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 9516414_1 CDM 636 RC J2405 HCPCS outpatient 7 5.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 6.23 89 999999999 5.46 6.65 percent of total billed charges "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 9516414_1 CDM 636 RC J2405 HCPCS outpatient 7 5.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 6.23 89 999999999 5.46 6.65 percent of total billed charges "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 9516414_1 CDM 636 RC J2405 HCPCS outpatient 7 5.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 6.3 90 999999999 5.46 6.65 percent of total billed charges "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 9516414_1 CDM 636 RC J2405 HCPCS outpatient 7 5.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 6.65 95 999999999 5.46 6.65 percent of total billed charges "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 9516414_1 CDM 636 RC J2405 HCPCS outpatient 7 5.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 6.65 95 999999999 5.46 6.65 percent of total billed charges "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 9516414_1 CDM 636 RC J2405 HCPCS outpatient 7 5.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 6.23 89 999999999 5.46 6.65 percent of total billed charges "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 9516414_1 CDM 636 RC J2405 HCPCS outpatient 7 5.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 6.16 88 999999999 5.46 6.65 percent of total billed charges "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 9516414_1 CDM 636 RC J2405 HCPCS outpatient 7 5.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 6.23 89 999999999 5.46 6.65 percent of total billed charges "INJECTION, PROMETHAZINE HCL, UP TO 50 MG" 9516415_1 CDM 636 RC J2550 HCPCS outpatient 28 21 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 25.2 90 999999999 21.84 26.6 percent of total billed charges "INJECTION, PROMETHAZINE HCL, UP TO 50 MG" 9516415_1 CDM 636 RC J2550 HCPCS outpatient 28 21 AETNA MCR ADV AETNA MCR ADV 21.84 78 999999999 21.84 26.6 percent of total billed charges "INJECTION, PROMETHAZINE HCL, UP TO 50 MG" 9516415_1 CDM 636 RC J2550 HCPCS outpatient 28 21 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 24.52 87.57 999999999 21.84 26.6 percent of total billed charges "INJECTION, PROMETHAZINE HCL, UP TO 50 MG" 9516415_1 CDM 636 RC J2550 HCPCS outpatient 28 21 COORDINATED CARE MCAID COORDINATED CARE MCAID 23.82 85.07 999999999 21.84 26.6 percent of total billed charges "INJECTION, PROMETHAZINE HCL, UP TO 50 MG" 9516415_1 CDM 636 RC J2550 HCPCS outpatient 28 21 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 23.82 85.07 999999999 21.84 26.6 percent of total billed charges "INJECTION, PROMETHAZINE HCL, UP TO 50 MG" 9516415_1 CDM 636 RC J2550 HCPCS outpatient 28 21 MOLINA MCAID MOLINA MCAID 23.35 83.4 999999999 21.84 26.6 percent of total billed charges "INJECTION, PROMETHAZINE HCL, UP TO 50 MG" 9516415_1 CDM 636 RC J2550 HCPCS outpatient 28 21 MOLINA MCR ADV MOLINA MCR ADV 24.92 89 999999999 21.84 26.6 percent of total billed charges "INJECTION, PROMETHAZINE HCL, UP TO 50 MG" 9516415_1 CDM 636 RC J2550 HCPCS outpatient 28 21 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 24.92 89 999999999 21.84 26.6 percent of total billed charges "INJECTION, PROMETHAZINE HCL, UP TO 50 MG" 9516415_1 CDM 636 RC J2550 HCPCS outpatient 28 21 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 24.92 89 999999999 21.84 26.6 percent of total billed charges "INJECTION, PROMETHAZINE HCL, UP TO 50 MG" 9516415_1 CDM 636 RC J2550 HCPCS outpatient 28 21 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 25.2 90 999999999 21.84 26.6 percent of total billed charges "INJECTION, PROMETHAZINE HCL, UP TO 50 MG" 9516415_1 CDM 636 RC J2550 HCPCS outpatient 28 21 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 26.6 95 999999999 21.84 26.6 percent of total billed charges "INJECTION, PROMETHAZINE HCL, UP TO 50 MG" 9516415_1 CDM 636 RC J2550 HCPCS outpatient 28 21 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 26.6 95 999999999 21.84 26.6 percent of total billed charges "INJECTION, PROMETHAZINE HCL, UP TO 50 MG" 9516415_1 CDM 636 RC J2550 HCPCS outpatient 28 21 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 24.92 89 999999999 21.84 26.6 percent of total billed charges "INJECTION, PROMETHAZINE HCL, UP TO 50 MG" 9516415_1 CDM 636 RC J2550 HCPCS outpatient 28 21 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 24.64 88 999999999 21.84 26.6 percent of total billed charges "INJECTION, PROMETHAZINE HCL, UP TO 50 MG" 9516415_1 CDM 636 RC J2550 HCPCS outpatient 28 21 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 24.92 89 999999999 21.84 26.6 percent of total billed charges "PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT (PPSV23), ADULT OR IMMUNOSUPPRESSED PATIENT DOSAGE, WHEN ADMINISTERED TO INDIVIDUALS 2 YEARS OR OLDER, FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 9516423_1 CDM 636 RC 90732 HCPCS outpatient 187 140.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 168.3 90 999999999 145.86 177.65 percent of total billed charges "PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT (PPSV23), ADULT OR IMMUNOSUPPRESSED PATIENT DOSAGE, WHEN ADMINISTERED TO INDIVIDUALS 2 YEARS OR OLDER, FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 9516423_1 CDM 636 RC 90732 HCPCS outpatient 187 140.25 AETNA MCR ADV AETNA MCR ADV 145.86 78 999999999 145.86 177.65 percent of total billed charges "PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT (PPSV23), ADULT OR IMMUNOSUPPRESSED PATIENT DOSAGE, WHEN ADMINISTERED TO INDIVIDUALS 2 YEARS OR OLDER, FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 9516423_1 CDM 636 RC 90732 HCPCS outpatient 187 140.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 163.76 87.57 999999999 145.86 177.65 percent of total billed charges "PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT (PPSV23), ADULT OR IMMUNOSUPPRESSED PATIENT DOSAGE, WHEN ADMINISTERED TO INDIVIDUALS 2 YEARS OR OLDER, FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 9516423_1 CDM 636 RC 90732 HCPCS outpatient 187 140.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 159.08 85.07 999999999 145.86 177.65 percent of total billed charges "PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT (PPSV23), ADULT OR IMMUNOSUPPRESSED PATIENT DOSAGE, WHEN ADMINISTERED TO INDIVIDUALS 2 YEARS OR OLDER, FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 9516423_1 CDM 636 RC 90732 HCPCS outpatient 187 140.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 159.08 85.07 999999999 145.86 177.65 percent of total billed charges "PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT (PPSV23), ADULT OR IMMUNOSUPPRESSED PATIENT DOSAGE, WHEN ADMINISTERED TO INDIVIDUALS 2 YEARS OR OLDER, FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 9516423_1 CDM 636 RC 90732 HCPCS outpatient 187 140.25 MOLINA MCAID MOLINA MCAID 155.96 83.4 999999999 145.86 177.65 percent of total billed charges "PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT (PPSV23), ADULT OR IMMUNOSUPPRESSED PATIENT DOSAGE, WHEN ADMINISTERED TO INDIVIDUALS 2 YEARS OR OLDER, FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 9516423_1 CDM 636 RC 90732 HCPCS outpatient 187 140.25 MOLINA MCR ADV MOLINA MCR ADV 166.43 89 999999999 145.86 177.65 percent of total billed charges "PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT (PPSV23), ADULT OR IMMUNOSUPPRESSED PATIENT DOSAGE, WHEN ADMINISTERED TO INDIVIDUALS 2 YEARS OR OLDER, FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 9516423_1 CDM 636 RC 90732 HCPCS outpatient 187 140.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 166.43 89 999999999 145.86 177.65 percent of total billed charges "PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT (PPSV23), ADULT OR IMMUNOSUPPRESSED PATIENT DOSAGE, WHEN ADMINISTERED TO INDIVIDUALS 2 YEARS OR OLDER, FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 9516423_1 CDM 636 RC 90732 HCPCS outpatient 187 140.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 166.43 89 999999999 145.86 177.65 percent of total billed charges "PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT (PPSV23), ADULT OR IMMUNOSUPPRESSED PATIENT DOSAGE, WHEN ADMINISTERED TO INDIVIDUALS 2 YEARS OR OLDER, FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 9516423_1 CDM 636 RC 90732 HCPCS outpatient 187 140.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 168.3 90 999999999 145.86 177.65 percent of total billed charges "PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT (PPSV23), ADULT OR IMMUNOSUPPRESSED PATIENT DOSAGE, WHEN ADMINISTERED TO INDIVIDUALS 2 YEARS OR OLDER, FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 9516423_1 CDM 636 RC 90732 HCPCS outpatient 187 140.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 177.65 95 999999999 145.86 177.65 percent of total billed charges "PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT (PPSV23), ADULT OR IMMUNOSUPPRESSED PATIENT DOSAGE, WHEN ADMINISTERED TO INDIVIDUALS 2 YEARS OR OLDER, FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 9516423_1 CDM 636 RC 90732 HCPCS outpatient 187 140.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 177.65 95 999999999 145.86 177.65 percent of total billed charges "PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT (PPSV23), ADULT OR IMMUNOSUPPRESSED PATIENT DOSAGE, WHEN ADMINISTERED TO INDIVIDUALS 2 YEARS OR OLDER, FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 9516423_1 CDM 636 RC 90732 HCPCS outpatient 187 140.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 166.43 89 999999999 145.86 177.65 percent of total billed charges "PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT (PPSV23), ADULT OR IMMUNOSUPPRESSED PATIENT DOSAGE, WHEN ADMINISTERED TO INDIVIDUALS 2 YEARS OR OLDER, FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 9516423_1 CDM 636 RC 90732 HCPCS outpatient 187 140.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 164.56 88 999999999 145.86 177.65 percent of total billed charges "PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT (PPSV23), ADULT OR IMMUNOSUPPRESSED PATIENT DOSAGE, WHEN ADMINISTERED TO INDIVIDUALS 2 YEARS OR OLDER, FOR SUBCUTANEOUS OR INTRAMUSCULAR USE" 9516423_1 CDM 636 RC 90732 HCPCS outpatient 187 140.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 166.43 89 999999999 145.86 177.65 percent of total billed charges "MEDICAL TEAM CONFERENCE WITH INTERDISCIPLINARY TEAM OF HEALTH CARE PROFESSIONALS, FACE-TO-FACE WITH PATIENT AND/OR FAMILY, 30 MINUTES OR MORE, PARTICIPATION BY NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL" 9516458_1 CDM 900 RC 99366 HCPCS outpatient 120 90 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 108 90 999999999 93.6 114 percent of total billed charges "MEDICAL TEAM CONFERENCE WITH INTERDISCIPLINARY TEAM OF HEALTH CARE PROFESSIONALS, FACE-TO-FACE WITH PATIENT AND/OR FAMILY, 30 MINUTES OR MORE, PARTICIPATION BY NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL" 9516458_1 CDM 900 RC 99366 HCPCS outpatient 120 90 AETNA MCR ADV AETNA MCR ADV 93.6 78 999999999 93.6 114 percent of total billed charges "MEDICAL TEAM CONFERENCE WITH INTERDISCIPLINARY TEAM OF HEALTH CARE PROFESSIONALS, FACE-TO-FACE WITH PATIENT AND/OR FAMILY, 30 MINUTES OR MORE, PARTICIPATION BY NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL" 9516458_1 CDM 900 RC 99366 HCPCS outpatient 120 90 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 105.08 87.57 999999999 93.6 114 percent of total billed charges "MEDICAL TEAM CONFERENCE WITH INTERDISCIPLINARY TEAM OF HEALTH CARE PROFESSIONALS, FACE-TO-FACE WITH PATIENT AND/OR FAMILY, 30 MINUTES OR MORE, PARTICIPATION BY NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL" 9516458_1 CDM 900 RC 99366 HCPCS outpatient 120 90 COORDINATED CARE MCAID COORDINATED CARE MCAID 102.08 85.07 999999999 93.6 114 percent of total billed charges "MEDICAL TEAM CONFERENCE WITH INTERDISCIPLINARY TEAM OF HEALTH CARE PROFESSIONALS, FACE-TO-FACE WITH PATIENT AND/OR FAMILY, 30 MINUTES OR MORE, PARTICIPATION BY NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL" 9516458_1 CDM 900 RC 99366 HCPCS outpatient 120 90 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 102.08 85.07 999999999 93.6 114 percent of total billed charges "MEDICAL TEAM CONFERENCE WITH INTERDISCIPLINARY TEAM OF HEALTH CARE PROFESSIONALS, FACE-TO-FACE WITH PATIENT AND/OR FAMILY, 30 MINUTES OR MORE, PARTICIPATION BY NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL" 9516458_1 CDM 900 RC 99366 HCPCS outpatient 120 90 MOLINA MCAID MOLINA MCAID 100.08 83.4 999999999 93.6 114 percent of total billed charges "MEDICAL TEAM CONFERENCE WITH INTERDISCIPLINARY TEAM OF HEALTH CARE PROFESSIONALS, FACE-TO-FACE WITH PATIENT AND/OR FAMILY, 30 MINUTES OR MORE, PARTICIPATION BY NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL" 9516458_1 CDM 900 RC 99366 HCPCS outpatient 120 90 MOLINA MCR ADV MOLINA MCR ADV 106.8 89 999999999 93.6 114 percent of total billed charges "MEDICAL TEAM CONFERENCE WITH INTERDISCIPLINARY TEAM OF HEALTH CARE PROFESSIONALS, FACE-TO-FACE WITH PATIENT AND/OR FAMILY, 30 MINUTES OR MORE, PARTICIPATION BY NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL" 9516458_1 CDM 900 RC 99366 HCPCS outpatient 120 90 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 106.8 89 999999999 93.6 114 percent of total billed charges "MEDICAL TEAM CONFERENCE WITH INTERDISCIPLINARY TEAM OF HEALTH CARE PROFESSIONALS, FACE-TO-FACE WITH PATIENT AND/OR FAMILY, 30 MINUTES OR MORE, PARTICIPATION BY NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL" 9516458_1 CDM 900 RC 99366 HCPCS outpatient 120 90 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 106.8 89 999999999 93.6 114 percent of total billed charges "MEDICAL TEAM CONFERENCE WITH INTERDISCIPLINARY TEAM OF HEALTH CARE PROFESSIONALS, FACE-TO-FACE WITH PATIENT AND/OR FAMILY, 30 MINUTES OR MORE, PARTICIPATION BY NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL" 9516458_1 CDM 900 RC 99366 HCPCS outpatient 120 90 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 108 90 999999999 93.6 114 percent of total billed charges "MEDICAL TEAM CONFERENCE WITH INTERDISCIPLINARY TEAM OF HEALTH CARE PROFESSIONALS, FACE-TO-FACE WITH PATIENT AND/OR FAMILY, 30 MINUTES OR MORE, PARTICIPATION BY NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL" 9516458_1 CDM 900 RC 99366 HCPCS outpatient 120 90 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 114 95 999999999 93.6 114 percent of total billed charges "MEDICAL TEAM CONFERENCE WITH INTERDISCIPLINARY TEAM OF HEALTH CARE PROFESSIONALS, FACE-TO-FACE WITH PATIENT AND/OR FAMILY, 30 MINUTES OR MORE, PARTICIPATION BY NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL" 9516458_1 CDM 900 RC 99366 HCPCS outpatient 120 90 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 114 95 999999999 93.6 114 percent of total billed charges "MEDICAL TEAM CONFERENCE WITH INTERDISCIPLINARY TEAM OF HEALTH CARE PROFESSIONALS, FACE-TO-FACE WITH PATIENT AND/OR FAMILY, 30 MINUTES OR MORE, PARTICIPATION BY NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL" 9516458_1 CDM 900 RC 99366 HCPCS outpatient 120 90 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 106.8 89 999999999 93.6 114 percent of total billed charges "MEDICAL TEAM CONFERENCE WITH INTERDISCIPLINARY TEAM OF HEALTH CARE PROFESSIONALS, FACE-TO-FACE WITH PATIENT AND/OR FAMILY, 30 MINUTES OR MORE, PARTICIPATION BY NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL" 9516458_1 CDM 900 RC 99366 HCPCS outpatient 120 90 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 105.6 88 999999999 93.6 114 percent of total billed charges "MEDICAL TEAM CONFERENCE WITH INTERDISCIPLINARY TEAM OF HEALTH CARE PROFESSIONALS, FACE-TO-FACE WITH PATIENT AND/OR FAMILY, 30 MINUTES OR MORE, PARTICIPATION BY NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL" 9516458_1 CDM 900 RC 99366 HCPCS outpatient 120 90 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 106.8 89 999999999 93.6 114 percent of total billed charges "ASSESSMENT OF APHASIA (INCLUDES ASSESSMENT OF EXPRESSIVE AND RECEPTIVE SPEECH AND LANGUAGE FUNCTION, LANGUAGE COMPREHENSION, SPEECH PRODUCTION ABILITY, READING, SPELLING, WRITING, EG, BY BOSTON DIAGNOSTIC APHASIA EXAMINATION) WITH INTERPRETATION AND REPORT, PER HOUR" 951985_1 CDM 440 RC 96105 HCPCS outpatient 325 243.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 292.5 90 999999999 253.5 308.75 percent of total billed charges "ASSESSMENT OF APHASIA (INCLUDES ASSESSMENT OF EXPRESSIVE AND RECEPTIVE SPEECH AND LANGUAGE FUNCTION, LANGUAGE COMPREHENSION, SPEECH PRODUCTION ABILITY, READING, SPELLING, WRITING, EG, BY BOSTON DIAGNOSTIC APHASIA EXAMINATION) WITH INTERPRETATION AND REPORT, PER HOUR" 951985_1 CDM 440 RC 96105 HCPCS outpatient 325 243.75 AETNA MCR ADV AETNA MCR ADV 253.5 78 999999999 253.5 308.75 percent of total billed charges "ASSESSMENT OF APHASIA (INCLUDES ASSESSMENT OF EXPRESSIVE AND RECEPTIVE SPEECH AND LANGUAGE FUNCTION, LANGUAGE COMPREHENSION, SPEECH PRODUCTION ABILITY, READING, SPELLING, WRITING, EG, BY BOSTON DIAGNOSTIC APHASIA EXAMINATION) WITH INTERPRETATION AND REPORT, PER HOUR" 951985_1 CDM 440 RC 96105 HCPCS outpatient 325 243.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 284.6 87.57 999999999 253.5 308.75 percent of total billed charges "ASSESSMENT OF APHASIA (INCLUDES ASSESSMENT OF EXPRESSIVE AND RECEPTIVE SPEECH AND LANGUAGE FUNCTION, LANGUAGE COMPREHENSION, SPEECH PRODUCTION ABILITY, READING, SPELLING, WRITING, EG, BY BOSTON DIAGNOSTIC APHASIA EXAMINATION) WITH INTERPRETATION AND REPORT, PER HOUR" 951985_1 CDM 440 RC 96105 HCPCS outpatient 325 243.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 276.48 85.07 999999999 253.5 308.75 percent of total billed charges "ASSESSMENT OF APHASIA (INCLUDES ASSESSMENT OF EXPRESSIVE AND RECEPTIVE SPEECH AND LANGUAGE FUNCTION, LANGUAGE COMPREHENSION, SPEECH PRODUCTION ABILITY, READING, SPELLING, WRITING, EG, BY BOSTON DIAGNOSTIC APHASIA EXAMINATION) WITH INTERPRETATION AND REPORT, PER HOUR" 951985_1 CDM 440 RC 96105 HCPCS outpatient 325 243.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 276.48 85.07 999999999 253.5 308.75 percent of total billed charges "ASSESSMENT OF APHASIA (INCLUDES ASSESSMENT OF EXPRESSIVE AND RECEPTIVE SPEECH AND LANGUAGE FUNCTION, LANGUAGE COMPREHENSION, SPEECH PRODUCTION ABILITY, READING, SPELLING, WRITING, EG, BY BOSTON DIAGNOSTIC APHASIA EXAMINATION) WITH INTERPRETATION AND REPORT, PER HOUR" 951985_1 CDM 440 RC 96105 HCPCS outpatient 325 243.75 MOLINA MCAID MOLINA MCAID 271.05 83.4 999999999 253.5 308.75 percent of total billed charges "ASSESSMENT OF APHASIA (INCLUDES ASSESSMENT OF EXPRESSIVE AND RECEPTIVE SPEECH AND LANGUAGE FUNCTION, LANGUAGE COMPREHENSION, SPEECH PRODUCTION ABILITY, READING, SPELLING, WRITING, EG, BY BOSTON DIAGNOSTIC APHASIA EXAMINATION) WITH INTERPRETATION AND REPORT, PER HOUR" 951985_1 CDM 440 RC 96105 HCPCS outpatient 325 243.75 MOLINA MCR ADV MOLINA MCR ADV 289.25 89 999999999 253.5 308.75 percent of total billed charges "ASSESSMENT OF APHASIA (INCLUDES ASSESSMENT OF EXPRESSIVE AND RECEPTIVE SPEECH AND LANGUAGE FUNCTION, LANGUAGE COMPREHENSION, SPEECH PRODUCTION ABILITY, READING, SPELLING, WRITING, EG, BY BOSTON DIAGNOSTIC APHASIA EXAMINATION) WITH INTERPRETATION AND REPORT, PER HOUR" 951985_1 CDM 440 RC 96105 HCPCS outpatient 325 243.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 289.25 89 999999999 253.5 308.75 percent of total billed charges "ASSESSMENT OF APHASIA (INCLUDES ASSESSMENT OF EXPRESSIVE AND RECEPTIVE SPEECH AND LANGUAGE FUNCTION, LANGUAGE COMPREHENSION, SPEECH PRODUCTION ABILITY, READING, SPELLING, WRITING, EG, BY BOSTON DIAGNOSTIC APHASIA EXAMINATION) WITH INTERPRETATION AND REPORT, PER HOUR" 951985_1 CDM 440 RC 96105 HCPCS outpatient 325 243.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 289.25 89 999999999 253.5 308.75 percent of total billed charges "ASSESSMENT OF APHASIA (INCLUDES ASSESSMENT OF EXPRESSIVE AND RECEPTIVE SPEECH AND LANGUAGE FUNCTION, LANGUAGE COMPREHENSION, SPEECH PRODUCTION ABILITY, READING, SPELLING, WRITING, EG, BY BOSTON DIAGNOSTIC APHASIA EXAMINATION) WITH INTERPRETATION AND REPORT, PER HOUR" 951985_1 CDM 440 RC 96105 HCPCS outpatient 325 243.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 292.5 90 999999999 253.5 308.75 percent of total billed charges "ASSESSMENT OF APHASIA (INCLUDES ASSESSMENT OF EXPRESSIVE AND RECEPTIVE SPEECH AND LANGUAGE FUNCTION, LANGUAGE COMPREHENSION, SPEECH PRODUCTION ABILITY, READING, SPELLING, WRITING, EG, BY BOSTON DIAGNOSTIC APHASIA EXAMINATION) WITH INTERPRETATION AND REPORT, PER HOUR" 951985_1 CDM 440 RC 96105 HCPCS outpatient 325 243.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 308.75 95 999999999 253.5 308.75 percent of total billed charges "ASSESSMENT OF APHASIA (INCLUDES ASSESSMENT OF EXPRESSIVE AND RECEPTIVE SPEECH AND LANGUAGE FUNCTION, LANGUAGE COMPREHENSION, SPEECH PRODUCTION ABILITY, READING, SPELLING, WRITING, EG, BY BOSTON DIAGNOSTIC APHASIA EXAMINATION) WITH INTERPRETATION AND REPORT, PER HOUR" 951985_1 CDM 440 RC 96105 HCPCS outpatient 325 243.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 308.75 95 999999999 253.5 308.75 percent of total billed charges "ASSESSMENT OF APHASIA (INCLUDES ASSESSMENT OF EXPRESSIVE AND RECEPTIVE SPEECH AND LANGUAGE FUNCTION, LANGUAGE COMPREHENSION, SPEECH PRODUCTION ABILITY, READING, SPELLING, WRITING, EG, BY BOSTON DIAGNOSTIC APHASIA EXAMINATION) WITH INTERPRETATION AND REPORT, PER HOUR" 951985_1 CDM 440 RC 96105 HCPCS outpatient 325 243.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 289.25 89 999999999 253.5 308.75 percent of total billed charges "ASSESSMENT OF APHASIA (INCLUDES ASSESSMENT OF EXPRESSIVE AND RECEPTIVE SPEECH AND LANGUAGE FUNCTION, LANGUAGE COMPREHENSION, SPEECH PRODUCTION ABILITY, READING, SPELLING, WRITING, EG, BY BOSTON DIAGNOSTIC APHASIA EXAMINATION) WITH INTERPRETATION AND REPORT, PER HOUR" 951985_1 CDM 440 RC 96105 HCPCS outpatient 325 243.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 286 88 999999999 253.5 308.75 percent of total billed charges "ASSESSMENT OF APHASIA (INCLUDES ASSESSMENT OF EXPRESSIVE AND RECEPTIVE SPEECH AND LANGUAGE FUNCTION, LANGUAGE COMPREHENSION, SPEECH PRODUCTION ABILITY, READING, SPELLING, WRITING, EG, BY BOSTON DIAGNOSTIC APHASIA EXAMINATION) WITH INTERPRETATION AND REPORT, PER HOUR" 951985_1 CDM 440 RC 96105 HCPCS outpatient 325 243.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 289.25 89 999999999 253.5 308.75 percent of total billed charges "ACOUSTIC REFLEX TESTING, THRESHOLD" 951987_1 CDM 471 RC 92568 HCPCS outpatient 142 106.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 127.8 90 999999999 110.76 134.9 percent of total billed charges "ACOUSTIC REFLEX TESTING, THRESHOLD" 951987_1 CDM 471 RC 92568 HCPCS outpatient 142 106.5 AETNA MCR ADV AETNA MCR ADV 110.76 78 999999999 110.76 134.9 percent of total billed charges "ACOUSTIC REFLEX TESTING, THRESHOLD" 951987_1 CDM 471 RC 92568 HCPCS outpatient 142 106.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 124.35 87.57 999999999 110.76 134.9 percent of total billed charges "ACOUSTIC REFLEX TESTING, THRESHOLD" 951987_1 CDM 471 RC 92568 HCPCS outpatient 142 106.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 120.8 85.07 999999999 110.76 134.9 percent of total billed charges "ACOUSTIC REFLEX TESTING, THRESHOLD" 951987_1 CDM 471 RC 92568 HCPCS outpatient 142 106.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 120.8 85.07 999999999 110.76 134.9 percent of total billed charges "ACOUSTIC REFLEX TESTING, THRESHOLD" 951987_1 CDM 471 RC 92568 HCPCS outpatient 142 106.5 MOLINA MCAID MOLINA MCAID 118.43 83.4 999999999 110.76 134.9 percent of total billed charges "ACOUSTIC REFLEX TESTING, THRESHOLD" 951987_1 CDM 471 RC 92568 HCPCS outpatient 142 106.5 MOLINA MCR ADV MOLINA MCR ADV 126.38 89 999999999 110.76 134.9 percent of total billed charges "ACOUSTIC REFLEX TESTING, THRESHOLD" 951987_1 CDM 471 RC 92568 HCPCS outpatient 142 106.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 126.38 89 999999999 110.76 134.9 percent of total billed charges "ACOUSTIC REFLEX TESTING, THRESHOLD" 951987_1 CDM 471 RC 92568 HCPCS outpatient 142 106.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 126.38 89 999999999 110.76 134.9 percent of total billed charges "ACOUSTIC REFLEX TESTING, THRESHOLD" 951987_1 CDM 471 RC 92568 HCPCS outpatient 142 106.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 127.8 90 999999999 110.76 134.9 percent of total billed charges "ACOUSTIC REFLEX TESTING, THRESHOLD" 951987_1 CDM 471 RC 92568 HCPCS outpatient 142 106.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 134.9 95 999999999 110.76 134.9 percent of total billed charges "ACOUSTIC REFLEX TESTING, THRESHOLD" 951987_1 CDM 471 RC 92568 HCPCS outpatient 142 106.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 134.9 95 999999999 110.76 134.9 percent of total billed charges "ACOUSTIC REFLEX TESTING, THRESHOLD" 951987_1 CDM 471 RC 92568 HCPCS outpatient 142 106.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 126.38 89 999999999 110.76 134.9 percent of total billed charges "ACOUSTIC REFLEX TESTING, THRESHOLD" 951987_1 CDM 471 RC 92568 HCPCS outpatient 142 106.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 124.96 88 999999999 110.76 134.9 percent of total billed charges "ACOUSTIC REFLEX TESTING, THRESHOLD" 951987_1 CDM 471 RC 92568 HCPCS outpatient 142 106.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 126.38 89 999999999 110.76 134.9 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); SUBCUTANEOUS OR INTRAMUSCULAR" 96372_3 CDM 510 RC 96372 HCPCS outpatient 29 21.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 26.1 90 999999999 22.62 27.55 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); SUBCUTANEOUS OR INTRAMUSCULAR" 96372_3 CDM 510 RC 96372 HCPCS outpatient 29 21.75 AETNA MCR ADV AETNA MCR ADV 22.62 78 999999999 22.62 27.55 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); SUBCUTANEOUS OR INTRAMUSCULAR" 96372_3 CDM 510 RC 96372 HCPCS outpatient 29 21.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 25.4 87.57 999999999 22.62 27.55 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); SUBCUTANEOUS OR INTRAMUSCULAR" 96372_3 CDM 510 RC 96372 HCPCS outpatient 29 21.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 24.67 85.07 999999999 22.62 27.55 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); SUBCUTANEOUS OR INTRAMUSCULAR" 96372_3 CDM 510 RC 96372 HCPCS outpatient 29 21.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 24.67 85.07 999999999 22.62 27.55 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); SUBCUTANEOUS OR INTRAMUSCULAR" 96372_3 CDM 510 RC 96372 HCPCS outpatient 29 21.75 MOLINA MCAID MOLINA MCAID 24.19 83.4 999999999 22.62 27.55 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); SUBCUTANEOUS OR INTRAMUSCULAR" 96372_3 CDM 510 RC 96372 HCPCS outpatient 29 21.75 MOLINA MCR ADV MOLINA MCR ADV 25.81 89 999999999 22.62 27.55 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); SUBCUTANEOUS OR INTRAMUSCULAR" 96372_3 CDM 510 RC 96372 HCPCS outpatient 29 21.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 25.81 89 999999999 22.62 27.55 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); SUBCUTANEOUS OR INTRAMUSCULAR" 96372_3 CDM 510 RC 96372 HCPCS outpatient 29 21.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 25.81 89 999999999 22.62 27.55 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); SUBCUTANEOUS OR INTRAMUSCULAR" 96372_3 CDM 510 RC 96372 HCPCS outpatient 29 21.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 26.1 90 999999999 22.62 27.55 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); SUBCUTANEOUS OR INTRAMUSCULAR" 96372_3 CDM 510 RC 96372 HCPCS outpatient 29 21.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 999999999 22.62 27.55 other Non-Covered [Rev Code] ( 1*0 ) Term Line 43 "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); SUBCUTANEOUS OR INTRAMUSCULAR" 96372_3 CDM 510 RC 96372 HCPCS outpatient 29 21.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 27.55 95 999999999 22.62 27.55 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); SUBCUTANEOUS OR INTRAMUSCULAR" 96372_3 CDM 510 RC 96372 HCPCS outpatient 29 21.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 25.81 89 999999999 22.62 27.55 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); SUBCUTANEOUS OR INTRAMUSCULAR" 96372_3 CDM 510 RC 96372 HCPCS outpatient 29 21.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 25.52 88 999999999 22.62 27.55 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); SUBCUTANEOUS OR INTRAMUSCULAR" 96372_3 CDM 510 RC 96372 HCPCS outpatient 29 21.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 25.81 89 999999999 22.62 27.55 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 96374_2 CDM 510 RC 96374 HCPCS outpatient 302 226.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 271.8 90 999999999 235.56 286.9 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 96374_2 CDM 510 RC 96374 HCPCS outpatient 302 226.5 AETNA MCR ADV AETNA MCR ADV 235.56 78 999999999 235.56 286.9 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 96374_2 CDM 510 RC 96374 HCPCS outpatient 302 226.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 264.46 87.57 999999999 235.56 286.9 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 96374_2 CDM 510 RC 96374 HCPCS outpatient 302 226.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 256.91 85.07 999999999 235.56 286.9 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 96374_2 CDM 510 RC 96374 HCPCS outpatient 302 226.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 256.91 85.07 999999999 235.56 286.9 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 96374_2 CDM 510 RC 96374 HCPCS outpatient 302 226.5 MOLINA MCAID MOLINA MCAID 251.87 83.4 999999999 235.56 286.9 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 96374_2 CDM 510 RC 96374 HCPCS outpatient 302 226.5 MOLINA MCR ADV MOLINA MCR ADV 268.78 89 999999999 235.56 286.9 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 96374_2 CDM 510 RC 96374 HCPCS outpatient 302 226.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 268.78 89 999999999 235.56 286.9 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 96374_2 CDM 510 RC 96374 HCPCS outpatient 302 226.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 268.78 89 999999999 235.56 286.9 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 96374_2 CDM 510 RC 96374 HCPCS outpatient 302 226.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 271.8 90 999999999 235.56 286.9 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 96374_2 CDM 510 RC 96374 HCPCS outpatient 302 226.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 999999999 235.56 286.9 other Non-Covered [Rev Code] ( 1*0 ) Term Line 43 "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 96374_2 CDM 510 RC 96374 HCPCS outpatient 302 226.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 286.9 95 999999999 235.56 286.9 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 96374_2 CDM 510 RC 96374 HCPCS outpatient 302 226.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 268.78 89 999999999 235.56 286.9 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 96374_2 CDM 510 RC 96374 HCPCS outpatient 302 226.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 265.76 88 999999999 235.56 286.9 percent of total billed charges "THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG" 96374_2 CDM 510 RC 96374 HCPCS outpatient 302 226.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 268.78 89 999999999 235.56 286.9 percent of total billed charges "REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), NON-SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA (EG, WET-TO-MOIST DRESSINGS, ENZYMATIC, ABRASION, LARVAL THERAPY), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION" 97602_1 CDM 761 RC 97602 HCPCS outpatient 234 175.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 210.6 90 999999999 182.52 222.3 percent of total billed charges "REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), NON-SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA (EG, WET-TO-MOIST DRESSINGS, ENZYMATIC, ABRASION, LARVAL THERAPY), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION" 97602_1 CDM 761 RC 97602 HCPCS outpatient 234 175.5 AETNA MCR ADV AETNA MCR ADV 182.52 78 999999999 182.52 222.3 percent of total billed charges "REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), NON-SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA (EG, WET-TO-MOIST DRESSINGS, ENZYMATIC, ABRASION, LARVAL THERAPY), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION" 97602_1 CDM 761 RC 97602 HCPCS outpatient 234 175.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 204.91 87.57 999999999 182.52 222.3 percent of total billed charges "REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), NON-SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA (EG, WET-TO-MOIST DRESSINGS, ENZYMATIC, ABRASION, LARVAL THERAPY), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION" 97602_1 CDM 761 RC 97602 HCPCS outpatient 234 175.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 199.06 85.07 999999999 182.52 222.3 percent of total billed charges "REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), NON-SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA (EG, WET-TO-MOIST DRESSINGS, ENZYMATIC, ABRASION, LARVAL THERAPY), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION" 97602_1 CDM 761 RC 97602 HCPCS outpatient 234 175.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 199.06 85.07 999999999 182.52 222.3 percent of total billed charges "REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), NON-SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA (EG, WET-TO-MOIST DRESSINGS, ENZYMATIC, ABRASION, LARVAL THERAPY), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION" 97602_1 CDM 761 RC 97602 HCPCS outpatient 234 175.5 MOLINA MCAID MOLINA MCAID 195.16 83.4 999999999 182.52 222.3 percent of total billed charges "REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), NON-SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA (EG, WET-TO-MOIST DRESSINGS, ENZYMATIC, ABRASION, LARVAL THERAPY), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION" 97602_1 CDM 761 RC 97602 HCPCS outpatient 234 175.5 MOLINA MCR ADV MOLINA MCR ADV 208.26 89 999999999 182.52 222.3 percent of total billed charges "REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), NON-SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA (EG, WET-TO-MOIST DRESSINGS, ENZYMATIC, ABRASION, LARVAL THERAPY), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION" 97602_1 CDM 761 RC 97602 HCPCS outpatient 234 175.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 208.26 89 999999999 182.52 222.3 percent of total billed charges "REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), NON-SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA (EG, WET-TO-MOIST DRESSINGS, ENZYMATIC, ABRASION, LARVAL THERAPY), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION" 97602_1 CDM 761 RC 97602 HCPCS outpatient 234 175.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 208.26 89 999999999 182.52 222.3 percent of total billed charges "REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), NON-SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA (EG, WET-TO-MOIST DRESSINGS, ENZYMATIC, ABRASION, LARVAL THERAPY), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION" 97602_1 CDM 761 RC 97602 HCPCS outpatient 234 175.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 210.6 90 999999999 182.52 222.3 percent of total billed charges "REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), NON-SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA (EG, WET-TO-MOIST DRESSINGS, ENZYMATIC, ABRASION, LARVAL THERAPY), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION" 97602_1 CDM 761 RC 97602 HCPCS outpatient 234 175.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 222.3 95 999999999 182.52 222.3 percent of total billed charges "REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), NON-SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA (EG, WET-TO-MOIST DRESSINGS, ENZYMATIC, ABRASION, LARVAL THERAPY), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION" 97602_1 CDM 761 RC 97602 HCPCS outpatient 234 175.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 222.3 95 999999999 182.52 222.3 percent of total billed charges "REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), NON-SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA (EG, WET-TO-MOIST DRESSINGS, ENZYMATIC, ABRASION, LARVAL THERAPY), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION" 97602_1 CDM 761 RC 97602 HCPCS outpatient 234 175.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 208.26 89 999999999 182.52 222.3 percent of total billed charges "REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), NON-SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA (EG, WET-TO-MOIST DRESSINGS, ENZYMATIC, ABRASION, LARVAL THERAPY), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION" 97602_1 CDM 761 RC 97602 HCPCS outpatient 234 175.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 205.92 88 999999999 182.52 222.3 percent of total billed charges "REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), NON-SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA (EG, WET-TO-MOIST DRESSINGS, ENZYMATIC, ABRASION, LARVAL THERAPY), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION" 97602_1 CDM 761 RC 97602 HCPCS outpatient 234 175.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 208.26 89 999999999 182.52 222.3 percent of total billed charges "REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), NON-SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA (EG, WET-TO-MOIST DRESSINGS, ENZYMATIC, ABRASION, LARVAL THERAPY), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION" 97602_3 CDM 761 RC 97602 HCPCS outpatient 260 195 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 234 90 999999999 202.8 247 percent of total billed charges "REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), NON-SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA (EG, WET-TO-MOIST DRESSINGS, ENZYMATIC, ABRASION, LARVAL THERAPY), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION" 97602_3 CDM 761 RC 97602 HCPCS outpatient 260 195 AETNA MCR ADV AETNA MCR ADV 202.8 78 999999999 202.8 247 percent of total billed charges "REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), NON-SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA (EG, WET-TO-MOIST DRESSINGS, ENZYMATIC, ABRASION, LARVAL THERAPY), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION" 97602_3 CDM 761 RC 97602 HCPCS outpatient 260 195 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 227.68 87.57 999999999 202.8 247 percent of total billed charges "REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), NON-SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA (EG, WET-TO-MOIST DRESSINGS, ENZYMATIC, ABRASION, LARVAL THERAPY), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION" 97602_3 CDM 761 RC 97602 HCPCS outpatient 260 195 COORDINATED CARE MCAID COORDINATED CARE MCAID 221.18 85.07 999999999 202.8 247 percent of total billed charges "REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), NON-SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA (EG, WET-TO-MOIST DRESSINGS, ENZYMATIC, ABRASION, LARVAL THERAPY), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION" 97602_3 CDM 761 RC 97602 HCPCS outpatient 260 195 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 221.18 85.07 999999999 202.8 247 percent of total billed charges "REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), NON-SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA (EG, WET-TO-MOIST DRESSINGS, ENZYMATIC, ABRASION, LARVAL THERAPY), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION" 97602_3 CDM 761 RC 97602 HCPCS outpatient 260 195 MOLINA MCAID MOLINA MCAID 216.84 83.4 999999999 202.8 247 percent of total billed charges "REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), NON-SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA (EG, WET-TO-MOIST DRESSINGS, ENZYMATIC, ABRASION, LARVAL THERAPY), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION" 97602_3 CDM 761 RC 97602 HCPCS outpatient 260 195 MOLINA MCR ADV MOLINA MCR ADV 231.4 89 999999999 202.8 247 percent of total billed charges "REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), NON-SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA (EG, WET-TO-MOIST DRESSINGS, ENZYMATIC, ABRASION, LARVAL THERAPY), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION" 97602_3 CDM 761 RC 97602 HCPCS outpatient 260 195 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 231.4 89 999999999 202.8 247 percent of total billed charges "REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), NON-SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA (EG, WET-TO-MOIST DRESSINGS, ENZYMATIC, ABRASION, LARVAL THERAPY), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION" 97602_3 CDM 761 RC 97602 HCPCS outpatient 260 195 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 231.4 89 999999999 202.8 247 percent of total billed charges "REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), NON-SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA (EG, WET-TO-MOIST DRESSINGS, ENZYMATIC, ABRASION, LARVAL THERAPY), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION" 97602_3 CDM 761 RC 97602 HCPCS outpatient 260 195 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 234 90 999999999 202.8 247 percent of total billed charges "REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), NON-SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA (EG, WET-TO-MOIST DRESSINGS, ENZYMATIC, ABRASION, LARVAL THERAPY), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION" 97602_3 CDM 761 RC 97602 HCPCS outpatient 260 195 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 247 95 999999999 202.8 247 percent of total billed charges "REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), NON-SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA (EG, WET-TO-MOIST DRESSINGS, ENZYMATIC, ABRASION, LARVAL THERAPY), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION" 97602_3 CDM 761 RC 97602 HCPCS outpatient 260 195 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 247 95 999999999 202.8 247 percent of total billed charges "REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), NON-SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA (EG, WET-TO-MOIST DRESSINGS, ENZYMATIC, ABRASION, LARVAL THERAPY), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION" 97602_3 CDM 761 RC 97602 HCPCS outpatient 260 195 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 231.4 89 999999999 202.8 247 percent of total billed charges "REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), NON-SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA (EG, WET-TO-MOIST DRESSINGS, ENZYMATIC, ABRASION, LARVAL THERAPY), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION" 97602_3 CDM 761 RC 97602 HCPCS outpatient 260 195 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 228.8 88 999999999 202.8 247 percent of total billed charges "REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), NON-SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA (EG, WET-TO-MOIST DRESSINGS, ENZYMATIC, ABRASION, LARVAL THERAPY), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION" 97602_3 CDM 761 RC 97602 HCPCS outpatient 260 195 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 231.4 89 999999999 202.8 247 percent of total billed charges "PHYSICAL PERFORMANCE TEST OR MEASUREMENT (EG, MUSCULOSKELETAL, FUNCTIONAL CAPACITY), WITH WRITTEN REPORT, EACH 15 MINUTES" 97750_3 CDM 430 RC 97750 HCPCS outpatient 70 52.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 63 90 999999999 54.6 66.5 percent of total billed charges "PHYSICAL PERFORMANCE TEST OR MEASUREMENT (EG, MUSCULOSKELETAL, FUNCTIONAL CAPACITY), WITH WRITTEN REPORT, EACH 15 MINUTES" 97750_3 CDM 430 RC 97750 HCPCS outpatient 70 52.5 AETNA MCR ADV AETNA MCR ADV 54.6 78 999999999 54.6 66.5 percent of total billed charges "PHYSICAL PERFORMANCE TEST OR MEASUREMENT (EG, MUSCULOSKELETAL, FUNCTIONAL CAPACITY), WITH WRITTEN REPORT, EACH 15 MINUTES" 97750_3 CDM 430 RC 97750 HCPCS outpatient 70 52.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 61.3 87.57 999999999 54.6 66.5 percent of total billed charges "PHYSICAL PERFORMANCE TEST OR MEASUREMENT (EG, MUSCULOSKELETAL, FUNCTIONAL CAPACITY), WITH WRITTEN REPORT, EACH 15 MINUTES" 97750_3 CDM 430 RC 97750 HCPCS outpatient 70 52.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 59.55 85.07 999999999 54.6 66.5 percent of total billed charges "PHYSICAL PERFORMANCE TEST OR MEASUREMENT (EG, MUSCULOSKELETAL, FUNCTIONAL CAPACITY), WITH WRITTEN REPORT, EACH 15 MINUTES" 97750_3 CDM 430 RC 97750 HCPCS outpatient 70 52.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 59.55 85.07 999999999 54.6 66.5 percent of total billed charges "PHYSICAL PERFORMANCE TEST OR MEASUREMENT (EG, MUSCULOSKELETAL, FUNCTIONAL CAPACITY), WITH WRITTEN REPORT, EACH 15 MINUTES" 97750_3 CDM 430 RC 97750 HCPCS outpatient 70 52.5 MOLINA MCAID MOLINA MCAID 58.38 83.4 999999999 54.6 66.5 percent of total billed charges "PHYSICAL PERFORMANCE TEST OR MEASUREMENT (EG, MUSCULOSKELETAL, FUNCTIONAL CAPACITY), WITH WRITTEN REPORT, EACH 15 MINUTES" 97750_3 CDM 430 RC 97750 HCPCS outpatient 70 52.5 MOLINA MCR ADV MOLINA MCR ADV 62.3 89 999999999 54.6 66.5 percent of total billed charges "PHYSICAL PERFORMANCE TEST OR MEASUREMENT (EG, MUSCULOSKELETAL, FUNCTIONAL CAPACITY), WITH WRITTEN REPORT, EACH 15 MINUTES" 97750_3 CDM 430 RC 97750 HCPCS outpatient 70 52.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 62.3 89 999999999 54.6 66.5 percent of total billed charges "PHYSICAL PERFORMANCE TEST OR MEASUREMENT (EG, MUSCULOSKELETAL, FUNCTIONAL CAPACITY), WITH WRITTEN REPORT, EACH 15 MINUTES" 97750_3 CDM 430 RC 97750 HCPCS outpatient 70 52.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 62.3 89 999999999 54.6 66.5 percent of total billed charges "PHYSICAL PERFORMANCE TEST OR MEASUREMENT (EG, MUSCULOSKELETAL, FUNCTIONAL CAPACITY), WITH WRITTEN REPORT, EACH 15 MINUTES" 97750_3 CDM 430 RC 97750 HCPCS outpatient 70 52.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 63 90 999999999 54.6 66.5 percent of total billed charges "PHYSICAL PERFORMANCE TEST OR MEASUREMENT (EG, MUSCULOSKELETAL, FUNCTIONAL CAPACITY), WITH WRITTEN REPORT, EACH 15 MINUTES" 97750_3 CDM 430 RC 97750 HCPCS outpatient 70 52.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 66.5 95 999999999 54.6 66.5 percent of total billed charges "PHYSICAL PERFORMANCE TEST OR MEASUREMENT (EG, MUSCULOSKELETAL, FUNCTIONAL CAPACITY), WITH WRITTEN REPORT, EACH 15 MINUTES" 97750_3 CDM 430 RC 97750 HCPCS outpatient 70 52.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 66.5 95 999999999 54.6 66.5 percent of total billed charges "PHYSICAL PERFORMANCE TEST OR MEASUREMENT (EG, MUSCULOSKELETAL, FUNCTIONAL CAPACITY), WITH WRITTEN REPORT, EACH 15 MINUTES" 97750_3 CDM 430 RC 97750 HCPCS outpatient 70 52.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 62.3 89 999999999 54.6 66.5 percent of total billed charges "PHYSICAL PERFORMANCE TEST OR MEASUREMENT (EG, MUSCULOSKELETAL, FUNCTIONAL CAPACITY), WITH WRITTEN REPORT, EACH 15 MINUTES" 97750_3 CDM 430 RC 97750 HCPCS outpatient 70 52.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 61.6 88 999999999 54.6 66.5 percent of total billed charges "PHYSICAL PERFORMANCE TEST OR MEASUREMENT (EG, MUSCULOSKELETAL, FUNCTIONAL CAPACITY), WITH WRITTEN REPORT, EACH 15 MINUTES" 97750_3 CDM 430 RC 97750 HCPCS outpatient 70 52.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 62.3 89 999999999 54.6 66.5 percent of total billed charges "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; INTERPRETATION AND REPORT ONLY" 9859301001_1 CDM 985 RC 93010 HCPCS outpatient 94 70.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 11.14 999999999 4.48 94 fee schedule "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; INTERPRETATION AND REPORT ONLY" 9859301001_1 CDM 985 RC 93010 HCPCS outpatient 94 70.5 AETNA MCR ADV AETNA MCR ADV 94 999999999 4.48 94 fee schedule "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; INTERPRETATION AND REPORT ONLY" 9859301001_1 CDM 985 RC 93010 HCPCS outpatient 94 70.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 4.7 999999999 4.48 94 fee schedule "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; INTERPRETATION AND REPORT ONLY" 9859301001_1 CDM 985 RC 93010 HCPCS outpatient 94 70.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 4.48 999999999 4.48 94 fee schedule "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; INTERPRETATION AND REPORT ONLY" 9859301001_1 CDM 985 RC 93010 HCPCS outpatient 94 70.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 94 999999999 4.48 94 fee schedule "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; INTERPRETATION AND REPORT ONLY" 9859301001_1 CDM 985 RC 93010 HCPCS outpatient 94 70.5 MOLINA MCAID MOLINA MCAID 4.7 999999999 4.48 94 fee schedule "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; INTERPRETATION AND REPORT ONLY" 9859301001_1 CDM 985 RC 93010 HCPCS outpatient 94 70.5 MOLINA MCR ADV MOLINA MCR ADV 94 999999999 4.48 94 fee schedule "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; INTERPRETATION AND REPORT ONLY" 9859301001_1 CDM 985 RC 93010 HCPCS outpatient 94 70.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 94 999999999 4.48 94 fee schedule "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; INTERPRETATION AND REPORT ONLY" 9859301001_1 CDM 985 RC 93010 HCPCS outpatient 94 70.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 94 999999999 4.48 94 fee schedule "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; INTERPRETATION AND REPORT ONLY" 9859301001_1 CDM 985 RC 93010 HCPCS outpatient 94 70.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 11.52 999999999 4.48 94 fee schedule "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; INTERPRETATION AND REPORT ONLY" 9859301001_1 CDM 985 RC 93010 HCPCS outpatient 94 70.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 12 999999999 4.48 94 fee schedule "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; INTERPRETATION AND REPORT ONLY" 9859301001_1 CDM 985 RC 93010 HCPCS outpatient 94 70.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 12 999999999 4.48 94 fee schedule "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; INTERPRETATION AND REPORT ONLY" 9859301001_1 CDM 985 RC 93010 HCPCS outpatient 94 70.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 94 999999999 4.48 94 fee schedule "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; INTERPRETATION AND REPORT ONLY" 9859301001_1 CDM 985 RC 93010 HCPCS outpatient 94 70.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 10.97 999999999 4.48 94 fee schedule "ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; INTERPRETATION AND REPORT ONLY" 9859301001_1 CDM 985 RC 93010 HCPCS outpatient 94 70.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 94 999999999 4.48 94 fee schedule "OBSERVATION CARE DISCHARGE DAY MANAGEMENT (THIS CODE IS TO BE UTILIZED TO REPORT ALL SERVICES PROVIDED TO A PATIENT ON DISCHARGE FROM OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" IF THE DISCHARGE IS ON OTHER THAN THE INITIAL DATE OF ""OBSERVATION STATUS."" TO REPORT SERVICES TO A PATIENT DESIGNATED AS ""OBSERVATION STATUS"" OR ""INPATIENT STATUS"" AND DISCHARGED ON THE SAME DATE, USE THE CODES FOR OBSERVATION OR INPATIENT CARE SERVICES [INCLUDING ADMISSION AND DISCHARGE SERVICES, 99234-99236 AS APPROPRIATE.])" 9879921701_1 CDM 987 RC 99217 HCPCS outpatient 269 201.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50.5 999999999 41.2 269 fee schedule "OBSERVATION CARE DISCHARGE DAY MANAGEMENT (THIS CODE IS TO BE UTILIZED TO REPORT ALL SERVICES PROVIDED TO A PATIENT ON DISCHARGE FROM OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" IF THE DISCHARGE IS ON OTHER THAN THE INITIAL DATE OF ""OBSERVATION STATUS."" TO REPORT SERVICES TO A PATIENT DESIGNATED AS ""OBSERVATION STATUS"" OR ""INPATIENT STATUS"" AND DISCHARGED ON THE SAME DATE, USE THE CODES FOR OBSERVATION OR INPATIENT CARE SERVICES [INCLUDING ADMISSION AND DISCHARGE SERVICES, 99234-99236 AS APPROPRIATE.])" 9879921701_1 CDM 987 RC 99217 HCPCS outpatient 269 201.75 AETNA MCR ADV AETNA MCR ADV 269 999999999 41.2 269 fee schedule "OBSERVATION CARE DISCHARGE DAY MANAGEMENT (THIS CODE IS TO BE UTILIZED TO REPORT ALL SERVICES PROVIDED TO A PATIENT ON DISCHARGE FROM OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" IF THE DISCHARGE IS ON OTHER THAN THE INITIAL DATE OF ""OBSERVATION STATUS."" TO REPORT SERVICES TO A PATIENT DESIGNATED AS ""OBSERVATION STATUS"" OR ""INPATIENT STATUS"" AND DISCHARGED ON THE SAME DATE, USE THE CODES FOR OBSERVATION OR INPATIENT CARE SERVICES [INCLUDING ADMISSION AND DISCHARGE SERVICES, 99234-99236 AS APPROPRIATE.])" 9879921701_1 CDM 987 RC 99217 HCPCS outpatient 269 201.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 43.26 999999999 41.2 269 fee schedule "OBSERVATION CARE DISCHARGE DAY MANAGEMENT (THIS CODE IS TO BE UTILIZED TO REPORT ALL SERVICES PROVIDED TO A PATIENT ON DISCHARGE FROM OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" IF THE DISCHARGE IS ON OTHER THAN THE INITIAL DATE OF ""OBSERVATION STATUS."" TO REPORT SERVICES TO A PATIENT DESIGNATED AS ""OBSERVATION STATUS"" OR ""INPATIENT STATUS"" AND DISCHARGED ON THE SAME DATE, USE THE CODES FOR OBSERVATION OR INPATIENT CARE SERVICES [INCLUDING ADMISSION AND DISCHARGE SERVICES, 99234-99236 AS APPROPRIATE.])" 9879921701_1 CDM 987 RC 99217 HCPCS outpatient 269 201.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 41.2 999999999 41.2 269 fee schedule "OBSERVATION CARE DISCHARGE DAY MANAGEMENT (THIS CODE IS TO BE UTILIZED TO REPORT ALL SERVICES PROVIDED TO A PATIENT ON DISCHARGE FROM OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" IF THE DISCHARGE IS ON OTHER THAN THE INITIAL DATE OF ""OBSERVATION STATUS."" TO REPORT SERVICES TO A PATIENT DESIGNATED AS ""OBSERVATION STATUS"" OR ""INPATIENT STATUS"" AND DISCHARGED ON THE SAME DATE, USE THE CODES FOR OBSERVATION OR INPATIENT CARE SERVICES [INCLUDING ADMISSION AND DISCHARGE SERVICES, 99234-99236 AS APPROPRIATE.])" 9879921701_1 CDM 987 RC 99217 HCPCS outpatient 269 201.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 269 999999999 41.2 269 fee schedule "OBSERVATION CARE DISCHARGE DAY MANAGEMENT (THIS CODE IS TO BE UTILIZED TO REPORT ALL SERVICES PROVIDED TO A PATIENT ON DISCHARGE FROM OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" IF THE DISCHARGE IS ON OTHER THAN THE INITIAL DATE OF ""OBSERVATION STATUS."" TO REPORT SERVICES TO A PATIENT DESIGNATED AS ""OBSERVATION STATUS"" OR ""INPATIENT STATUS"" AND DISCHARGED ON THE SAME DATE, USE THE CODES FOR OBSERVATION OR INPATIENT CARE SERVICES [INCLUDING ADMISSION AND DISCHARGE SERVICES, 99234-99236 AS APPROPRIATE.])" 9879921701_1 CDM 987 RC 99217 HCPCS outpatient 269 201.75 MOLINA MCAID MOLINA MCAID 43.26 999999999 41.2 269 fee schedule "OBSERVATION CARE DISCHARGE DAY MANAGEMENT (THIS CODE IS TO BE UTILIZED TO REPORT ALL SERVICES PROVIDED TO A PATIENT ON DISCHARGE FROM OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" IF THE DISCHARGE IS ON OTHER THAN THE INITIAL DATE OF ""OBSERVATION STATUS."" TO REPORT SERVICES TO A PATIENT DESIGNATED AS ""OBSERVATION STATUS"" OR ""INPATIENT STATUS"" AND DISCHARGED ON THE SAME DATE, USE THE CODES FOR OBSERVATION OR INPATIENT CARE SERVICES [INCLUDING ADMISSION AND DISCHARGE SERVICES, 99234-99236 AS APPROPRIATE.])" 9879921701_1 CDM 987 RC 99217 HCPCS outpatient 269 201.75 MOLINA MCR ADV MOLINA MCR ADV 269 999999999 41.2 269 fee schedule "OBSERVATION CARE DISCHARGE DAY MANAGEMENT (THIS CODE IS TO BE UTILIZED TO REPORT ALL SERVICES PROVIDED TO A PATIENT ON DISCHARGE FROM OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" IF THE DISCHARGE IS ON OTHER THAN THE INITIAL DATE OF ""OBSERVATION STATUS."" TO REPORT SERVICES TO A PATIENT DESIGNATED AS ""OBSERVATION STATUS"" OR ""INPATIENT STATUS"" AND DISCHARGED ON THE SAME DATE, USE THE CODES FOR OBSERVATION OR INPATIENT CARE SERVICES [INCLUDING ADMISSION AND DISCHARGE SERVICES, 99234-99236 AS APPROPRIATE.])" 9879921701_1 CDM 987 RC 99217 HCPCS outpatient 269 201.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 269 999999999 41.2 269 fee schedule "OBSERVATION CARE DISCHARGE DAY MANAGEMENT (THIS CODE IS TO BE UTILIZED TO REPORT ALL SERVICES PROVIDED TO A PATIENT ON DISCHARGE FROM OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" IF THE DISCHARGE IS ON OTHER THAN THE INITIAL DATE OF ""OBSERVATION STATUS."" TO REPORT SERVICES TO A PATIENT DESIGNATED AS ""OBSERVATION STATUS"" OR ""INPATIENT STATUS"" AND DISCHARGED ON THE SAME DATE, USE THE CODES FOR OBSERVATION OR INPATIENT CARE SERVICES [INCLUDING ADMISSION AND DISCHARGE SERVICES, 99234-99236 AS APPROPRIATE.])" 9879921701_1 CDM 987 RC 99217 HCPCS outpatient 269 201.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 269 999999999 41.2 269 fee schedule "OBSERVATION CARE DISCHARGE DAY MANAGEMENT (THIS CODE IS TO BE UTILIZED TO REPORT ALL SERVICES PROVIDED TO A PATIENT ON DISCHARGE FROM OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" IF THE DISCHARGE IS ON OTHER THAN THE INITIAL DATE OF ""OBSERVATION STATUS."" TO REPORT SERVICES TO A PATIENT DESIGNATED AS ""OBSERVATION STATUS"" OR ""INPATIENT STATUS"" AND DISCHARGED ON THE SAME DATE, USE THE CODES FOR OBSERVATION OR INPATIENT CARE SERVICES [INCLUDING ADMISSION AND DISCHARGE SERVICES, 99234-99236 AS APPROPRIATE.])" 9879921701_1 CDM 987 RC 99217 HCPCS outpatient 269 201.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 999999999 41.2 269 "OBSERVATION CARE DISCHARGE DAY MANAGEMENT (THIS CODE IS TO BE UTILIZED TO REPORT ALL SERVICES PROVIDED TO A PATIENT ON DISCHARGE FROM OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" IF THE DISCHARGE IS ON OTHER THAN THE INITIAL DATE OF ""OBSERVATION STATUS."" TO REPORT SERVICES TO A PATIENT DESIGNATED AS ""OBSERVATION STATUS"" OR ""INPATIENT STATUS"" AND DISCHARGED ON THE SAME DATE, USE THE CODES FOR OBSERVATION OR INPATIENT CARE SERVICES [INCLUDING ADMISSION AND DISCHARGE SERVICES, 99234-99236 AS APPROPRIATE.])" 9879921701_1 CDM 987 RC 99217 HCPCS outpatient 269 201.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 103.5 999999999 41.2 269 fee schedule "OBSERVATION CARE DISCHARGE DAY MANAGEMENT (THIS CODE IS TO BE UTILIZED TO REPORT ALL SERVICES PROVIDED TO A PATIENT ON DISCHARGE FROM OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" IF THE DISCHARGE IS ON OTHER THAN THE INITIAL DATE OF ""OBSERVATION STATUS."" TO REPORT SERVICES TO A PATIENT DESIGNATED AS ""OBSERVATION STATUS"" OR ""INPATIENT STATUS"" AND DISCHARGED ON THE SAME DATE, USE THE CODES FOR OBSERVATION OR INPATIENT CARE SERVICES [INCLUDING ADMISSION AND DISCHARGE SERVICES, 99234-99236 AS APPROPRIATE.])" 9879921701_1 CDM 987 RC 99217 HCPCS outpatient 269 201.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 103.5 999999999 41.2 269 fee schedule "OBSERVATION CARE DISCHARGE DAY MANAGEMENT (THIS CODE IS TO BE UTILIZED TO REPORT ALL SERVICES PROVIDED TO A PATIENT ON DISCHARGE FROM OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" IF THE DISCHARGE IS ON OTHER THAN THE INITIAL DATE OF ""OBSERVATION STATUS."" TO REPORT SERVICES TO A PATIENT DESIGNATED AS ""OBSERVATION STATUS"" OR ""INPATIENT STATUS"" AND DISCHARGED ON THE SAME DATE, USE THE CODES FOR OBSERVATION OR INPATIENT CARE SERVICES [INCLUDING ADMISSION AND DISCHARGE SERVICES, 99234-99236 AS APPROPRIATE.])" 9879921701_1 CDM 987 RC 99217 HCPCS outpatient 269 201.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 269 999999999 41.2 269 fee schedule "OBSERVATION CARE DISCHARGE DAY MANAGEMENT (THIS CODE IS TO BE UTILIZED TO REPORT ALL SERVICES PROVIDED TO A PATIENT ON DISCHARGE FROM OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" IF THE DISCHARGE IS ON OTHER THAN THE INITIAL DATE OF ""OBSERVATION STATUS."" TO REPORT SERVICES TO A PATIENT DESIGNATED AS ""OBSERVATION STATUS"" OR ""INPATIENT STATUS"" AND DISCHARGED ON THE SAME DATE, USE THE CODES FOR OBSERVATION OR INPATIENT CARE SERVICES [INCLUDING ADMISSION AND DISCHARGE SERVICES, 99234-99236 AS APPROPRIATE.])" 9879921701_1 CDM 987 RC 99217 HCPCS outpatient 269 201.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 999999999 41.2 269 "OBSERVATION CARE DISCHARGE DAY MANAGEMENT (THIS CODE IS TO BE UTILIZED TO REPORT ALL SERVICES PROVIDED TO A PATIENT ON DISCHARGE FROM OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" IF THE DISCHARGE IS ON OTHER THAN THE INITIAL DATE OF ""OBSERVATION STATUS."" TO REPORT SERVICES TO A PATIENT DESIGNATED AS ""OBSERVATION STATUS"" OR ""INPATIENT STATUS"" AND DISCHARGED ON THE SAME DATE, USE THE CODES FOR OBSERVATION OR INPATIENT CARE SERVICES [INCLUDING ADMISSION AND DISCHARGE SERVICES, 99234-99236 AS APPROPRIATE.])" 9879921701_1 CDM 987 RC 99217 HCPCS outpatient 269 201.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 269 999999999 41.2 269 fee schedule "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED OR COMPREHENSIVE HISTORY; A DETAILED OR COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF LOW SEVERITY. TYPICALLY, 30 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879921801_1 CDM 987 RC 99218 HCPCS outpatient 290 217.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50.5 999999999 50.5 290 fee schedule "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED OR COMPREHENSIVE HISTORY; A DETAILED OR COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF LOW SEVERITY. TYPICALLY, 30 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879921801_1 CDM 987 RC 99218 HCPCS outpatient 290 217.5 AETNA MCR ADV AETNA MCR ADV 290 999999999 50.5 290 fee schedule "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED OR COMPREHENSIVE HISTORY; A DETAILED OR COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF LOW SEVERITY. TYPICALLY, 30 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879921801_1 CDM 987 RC 99218 HCPCS outpatient 290 217.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 58.43 999999999 50.5 290 fee schedule "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED OR COMPREHENSIVE HISTORY; A DETAILED OR COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF LOW SEVERITY. TYPICALLY, 30 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879921801_1 CDM 987 RC 99218 HCPCS outpatient 290 217.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 55.65 999999999 50.5 290 fee schedule "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED OR COMPREHENSIVE HISTORY; A DETAILED OR COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF LOW SEVERITY. TYPICALLY, 30 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879921801_1 CDM 987 RC 99218 HCPCS outpatient 290 217.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 290 999999999 50.5 290 fee schedule "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED OR COMPREHENSIVE HISTORY; A DETAILED OR COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF LOW SEVERITY. TYPICALLY, 30 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879921801_1 CDM 987 RC 99218 HCPCS outpatient 290 217.5 MOLINA MCAID MOLINA MCAID 58.43 999999999 50.5 290 fee schedule "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED OR COMPREHENSIVE HISTORY; A DETAILED OR COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF LOW SEVERITY. TYPICALLY, 30 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879921801_1 CDM 987 RC 99218 HCPCS outpatient 290 217.5 MOLINA MCR ADV MOLINA MCR ADV 290 999999999 50.5 290 fee schedule "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED OR COMPREHENSIVE HISTORY; A DETAILED OR COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF LOW SEVERITY. TYPICALLY, 30 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879921801_1 CDM 987 RC 99218 HCPCS outpatient 290 217.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 290 999999999 50.5 290 fee schedule "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED OR COMPREHENSIVE HISTORY; A DETAILED OR COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF LOW SEVERITY. TYPICALLY, 30 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879921801_1 CDM 987 RC 99218 HCPCS outpatient 290 217.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 290 999999999 50.5 290 fee schedule "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED OR COMPREHENSIVE HISTORY; A DETAILED OR COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF LOW SEVERITY. TYPICALLY, 30 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879921801_1 CDM 987 RC 99218 HCPCS outpatient 290 217.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 999999999 50.5 290 "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED OR COMPREHENSIVE HISTORY; A DETAILED OR COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF LOW SEVERITY. TYPICALLY, 30 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879921801_1 CDM 987 RC 99218 HCPCS outpatient 290 217.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 141.5 999999999 50.5 290 fee schedule "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED OR COMPREHENSIVE HISTORY; A DETAILED OR COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF LOW SEVERITY. TYPICALLY, 30 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879921801_1 CDM 987 RC 99218 HCPCS outpatient 290 217.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 141.5 999999999 50.5 290 fee schedule "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED OR COMPREHENSIVE HISTORY; A DETAILED OR COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF LOW SEVERITY. TYPICALLY, 30 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879921801_1 CDM 987 RC 99218 HCPCS outpatient 290 217.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 290 999999999 50.5 290 fee schedule "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED OR COMPREHENSIVE HISTORY; A DETAILED OR COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF LOW SEVERITY. TYPICALLY, 30 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879921801_1 CDM 987 RC 99218 HCPCS outpatient 290 217.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 999999999 50.5 290 "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED OR COMPREHENSIVE HISTORY; A DETAILED OR COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF LOW SEVERITY. TYPICALLY, 30 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879921801_1 CDM 987 RC 99218 HCPCS outpatient 290 217.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 290 999999999 50.5 290 fee schedule "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF MODERATE SEVERITY. TYPICALLY, 50 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879921901_1 CDM 987 RC 99219 HCPCS outpatient 407 305.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50.5 999999999 50.5 407 fee schedule "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF MODERATE SEVERITY. TYPICALLY, 50 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879921901_1 CDM 987 RC 99219 HCPCS outpatient 407 305.25 AETNA MCR ADV AETNA MCR ADV 407 999999999 50.5 407 fee schedule "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF MODERATE SEVERITY. TYPICALLY, 50 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879921901_1 CDM 987 RC 99219 HCPCS outpatient 407 305.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 79.96 999999999 50.5 407 fee schedule "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF MODERATE SEVERITY. TYPICALLY, 50 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879921901_1 CDM 987 RC 99219 HCPCS outpatient 407 305.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 76.15 999999999 50.5 407 fee schedule "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF MODERATE SEVERITY. TYPICALLY, 50 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879921901_1 CDM 987 RC 99219 HCPCS outpatient 407 305.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 407 999999999 50.5 407 fee schedule "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF MODERATE SEVERITY. TYPICALLY, 50 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879921901_1 CDM 987 RC 99219 HCPCS outpatient 407 305.25 MOLINA MCAID MOLINA MCAID 79.96 999999999 50.5 407 fee schedule "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF MODERATE SEVERITY. TYPICALLY, 50 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879921901_1 CDM 987 RC 99219 HCPCS outpatient 407 305.25 MOLINA MCR ADV MOLINA MCR ADV 407 999999999 50.5 407 fee schedule "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF MODERATE SEVERITY. TYPICALLY, 50 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879921901_1 CDM 987 RC 99219 HCPCS outpatient 407 305.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 407 999999999 50.5 407 fee schedule "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF MODERATE SEVERITY. TYPICALLY, 50 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879921901_1 CDM 987 RC 99219 HCPCS outpatient 407 305.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 407 999999999 50.5 407 fee schedule "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF MODERATE SEVERITY. TYPICALLY, 50 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879921901_1 CDM 987 RC 99219 HCPCS outpatient 407 305.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 999999999 50.5 407 "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF MODERATE SEVERITY. TYPICALLY, 50 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879921901_1 CDM 987 RC 99219 HCPCS outpatient 407 305.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 192.5 999999999 50.5 407 fee schedule "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF MODERATE SEVERITY. TYPICALLY, 50 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879921901_1 CDM 987 RC 99219 HCPCS outpatient 407 305.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 192.5 999999999 50.5 407 fee schedule "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF MODERATE SEVERITY. TYPICALLY, 50 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879921901_1 CDM 987 RC 99219 HCPCS outpatient 407 305.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 407 999999999 50.5 407 fee schedule "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF MODERATE SEVERITY. TYPICALLY, 50 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879921901_1 CDM 987 RC 99219 HCPCS outpatient 407 305.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 999999999 50.5 407 "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF MODERATE SEVERITY. TYPICALLY, 50 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879921901_1 CDM 987 RC 99219 HCPCS outpatient 407 305.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 407 999999999 50.5 407 fee schedule "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF HIGH SEVERITY. TYPICALLY, 70 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922001_1 CDM 987 RC 99220 HCPCS outpatient 460 345 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50.5 999999999 50.5 460 fee schedule "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF HIGH SEVERITY. TYPICALLY, 70 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922001_1 CDM 987 RC 99220 HCPCS outpatient 460 345 AETNA MCR ADV AETNA MCR ADV 460 999999999 50.5 460 fee schedule "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF HIGH SEVERITY. TYPICALLY, 70 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922001_1 CDM 987 RC 99220 HCPCS outpatient 460 345 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 108.26 999999999 50.5 460 fee schedule "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF HIGH SEVERITY. TYPICALLY, 70 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922001_1 CDM 987 RC 99220 HCPCS outpatient 460 345 COORDINATED CARE MCAID COORDINATED CARE MCAID 103.1 999999999 50.5 460 fee schedule "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF HIGH SEVERITY. TYPICALLY, 70 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922001_1 CDM 987 RC 99220 HCPCS outpatient 460 345 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 460 999999999 50.5 460 fee schedule "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF HIGH SEVERITY. TYPICALLY, 70 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922001_1 CDM 987 RC 99220 HCPCS outpatient 460 345 MOLINA MCAID MOLINA MCAID 108.26 999999999 50.5 460 fee schedule "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF HIGH SEVERITY. TYPICALLY, 70 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922001_1 CDM 987 RC 99220 HCPCS outpatient 460 345 MOLINA MCR ADV MOLINA MCR ADV 460 999999999 50.5 460 fee schedule "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF HIGH SEVERITY. TYPICALLY, 70 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922001_1 CDM 987 RC 99220 HCPCS outpatient 460 345 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 460 999999999 50.5 460 fee schedule "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF HIGH SEVERITY. TYPICALLY, 70 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922001_1 CDM 987 RC 99220 HCPCS outpatient 460 345 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 460 999999999 50.5 460 fee schedule "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF HIGH SEVERITY. TYPICALLY, 70 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922001_1 CDM 987 RC 99220 HCPCS outpatient 460 345 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 999999999 50.5 460 "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF HIGH SEVERITY. TYPICALLY, 70 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922001_1 CDM 987 RC 99220 HCPCS outpatient 460 345 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 263.5 999999999 50.5 460 fee schedule "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF HIGH SEVERITY. TYPICALLY, 70 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922001_1 CDM 987 RC 99220 HCPCS outpatient 460 345 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 263.5 999999999 50.5 460 fee schedule "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF HIGH SEVERITY. TYPICALLY, 70 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922001_1 CDM 987 RC 99220 HCPCS outpatient 460 345 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 460 999999999 50.5 460 fee schedule "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF HIGH SEVERITY. TYPICALLY, 70 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922001_1 CDM 987 RC 99220 HCPCS outpatient 460 345 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 999999999 50.5 460 "INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO OUTPATIENT HOSPITAL ""OBSERVATION STATUS"" ARE OF HIGH SEVERITY. TYPICALLY, 70 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922001_1 CDM 987 RC 99220 HCPCS outpatient 460 345 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 460 999999999 50.5 460 fee schedule "SUBSEQUENT OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: PROBLEM FOCUSED INTERVAL HISTORY; PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PATIENT IS STABLE, RECOVERING, OR IMPROVING. TYPICALLY, 15 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922401_1 CDM 987 RC 99224 HCPCS outpatient 172 129 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50.5 999999999 22.06 172 fee schedule "SUBSEQUENT OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: PROBLEM FOCUSED INTERVAL HISTORY; PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PATIENT IS STABLE, RECOVERING, OR IMPROVING. TYPICALLY, 15 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922401_1 CDM 987 RC 99224 HCPCS outpatient 172 129 AETNA MCR ADV AETNA MCR ADV 172 999999999 22.06 172 fee schedule "SUBSEQUENT OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: PROBLEM FOCUSED INTERVAL HISTORY; PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PATIENT IS STABLE, RECOVERING, OR IMPROVING. TYPICALLY, 15 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922401_1 CDM 987 RC 99224 HCPCS outpatient 172 129 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 23.16 999999999 22.06 172 fee schedule "SUBSEQUENT OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: PROBLEM FOCUSED INTERVAL HISTORY; PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PATIENT IS STABLE, RECOVERING, OR IMPROVING. TYPICALLY, 15 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922401_1 CDM 987 RC 99224 HCPCS outpatient 172 129 COORDINATED CARE MCAID COORDINATED CARE MCAID 22.06 999999999 22.06 172 fee schedule "SUBSEQUENT OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: PROBLEM FOCUSED INTERVAL HISTORY; PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PATIENT IS STABLE, RECOVERING, OR IMPROVING. TYPICALLY, 15 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922401_1 CDM 987 RC 99224 HCPCS outpatient 172 129 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 172 999999999 22.06 172 fee schedule "SUBSEQUENT OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: PROBLEM FOCUSED INTERVAL HISTORY; PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PATIENT IS STABLE, RECOVERING, OR IMPROVING. TYPICALLY, 15 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922401_1 CDM 987 RC 99224 HCPCS outpatient 172 129 MOLINA MCAID MOLINA MCAID 23.16 999999999 22.06 172 fee schedule "SUBSEQUENT OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: PROBLEM FOCUSED INTERVAL HISTORY; PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PATIENT IS STABLE, RECOVERING, OR IMPROVING. TYPICALLY, 15 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922401_1 CDM 987 RC 99224 HCPCS outpatient 172 129 MOLINA MCR ADV MOLINA MCR ADV 172 999999999 22.06 172 fee schedule "SUBSEQUENT OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: PROBLEM FOCUSED INTERVAL HISTORY; PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PATIENT IS STABLE, RECOVERING, OR IMPROVING. TYPICALLY, 15 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922401_1 CDM 987 RC 99224 HCPCS outpatient 172 129 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 172 999999999 22.06 172 fee schedule "SUBSEQUENT OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: PROBLEM FOCUSED INTERVAL HISTORY; PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PATIENT IS STABLE, RECOVERING, OR IMPROVING. TYPICALLY, 15 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922401_1 CDM 987 RC 99224 HCPCS outpatient 172 129 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 172 999999999 22.06 172 fee schedule "SUBSEQUENT OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: PROBLEM FOCUSED INTERVAL HISTORY; PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PATIENT IS STABLE, RECOVERING, OR IMPROVING. TYPICALLY, 15 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922401_1 CDM 987 RC 99224 HCPCS outpatient 172 129 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 999999999 22.06 172 "SUBSEQUENT OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: PROBLEM FOCUSED INTERVAL HISTORY; PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PATIENT IS STABLE, RECOVERING, OR IMPROVING. TYPICALLY, 15 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922401_1 CDM 987 RC 99224 HCPCS outpatient 172 129 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 56.5 999999999 22.06 172 fee schedule "SUBSEQUENT OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: PROBLEM FOCUSED INTERVAL HISTORY; PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PATIENT IS STABLE, RECOVERING, OR IMPROVING. TYPICALLY, 15 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922401_1 CDM 987 RC 99224 HCPCS outpatient 172 129 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 56.5 999999999 22.06 172 fee schedule "SUBSEQUENT OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: PROBLEM FOCUSED INTERVAL HISTORY; PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PATIENT IS STABLE, RECOVERING, OR IMPROVING. TYPICALLY, 15 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922401_1 CDM 987 RC 99224 HCPCS outpatient 172 129 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 172 999999999 22.06 172 fee schedule "SUBSEQUENT OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: PROBLEM FOCUSED INTERVAL HISTORY; PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PATIENT IS STABLE, RECOVERING, OR IMPROVING. TYPICALLY, 15 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922401_1 CDM 987 RC 99224 HCPCS outpatient 172 129 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 999999999 22.06 172 "SUBSEQUENT OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: PROBLEM FOCUSED INTERVAL HISTORY; PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PATIENT IS STABLE, RECOVERING, OR IMPROVING. TYPICALLY, 15 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922401_1 CDM 987 RC 99224 HCPCS outpatient 172 129 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 172 999999999 22.06 172 fee schedule "SUBSEQUENT OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PATIENT IS RESPONDING INADEQUATELY TO THERAPY OR HAS DEVELOPED A MINOR COMPLICATION. TYPICALLY, 25 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922501_1 CDM 987 RC 99225 HCPCS outpatient 141 105.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 50.5 999999999 40.81 141 fee schedule "SUBSEQUENT OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PATIENT IS RESPONDING INADEQUATELY TO THERAPY OR HAS DEVELOPED A MINOR COMPLICATION. TYPICALLY, 25 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922501_1 CDM 987 RC 99225 HCPCS outpatient 141 105.75 AETNA MCR ADV AETNA MCR ADV 141 999999999 40.81 141 fee schedule "SUBSEQUENT OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PATIENT IS RESPONDING INADEQUATELY TO THERAPY OR HAS DEVELOPED A MINOR COMPLICATION. TYPICALLY, 25 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922501_1 CDM 987 RC 99225 HCPCS outpatient 141 105.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 42.85 999999999 40.81 141 fee schedule "SUBSEQUENT OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PATIENT IS RESPONDING INADEQUATELY TO THERAPY OR HAS DEVELOPED A MINOR COMPLICATION. TYPICALLY, 25 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922501_1 CDM 987 RC 99225 HCPCS outpatient 141 105.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 40.81 999999999 40.81 141 fee schedule "SUBSEQUENT OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PATIENT IS RESPONDING INADEQUATELY TO THERAPY OR HAS DEVELOPED A MINOR COMPLICATION. TYPICALLY, 25 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922501_1 CDM 987 RC 99225 HCPCS outpatient 141 105.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 141 999999999 40.81 141 fee schedule "SUBSEQUENT OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PATIENT IS RESPONDING INADEQUATELY TO THERAPY OR HAS DEVELOPED A MINOR COMPLICATION. TYPICALLY, 25 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922501_1 CDM 987 RC 99225 HCPCS outpatient 141 105.75 MOLINA MCAID MOLINA MCAID 42.85 999999999 40.81 141 fee schedule "SUBSEQUENT OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PATIENT IS RESPONDING INADEQUATELY TO THERAPY OR HAS DEVELOPED A MINOR COMPLICATION. TYPICALLY, 25 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922501_1 CDM 987 RC 99225 HCPCS outpatient 141 105.75 MOLINA MCR ADV MOLINA MCR ADV 141 999999999 40.81 141 fee schedule "SUBSEQUENT OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PATIENT IS RESPONDING INADEQUATELY TO THERAPY OR HAS DEVELOPED A MINOR COMPLICATION. TYPICALLY, 25 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922501_1 CDM 987 RC 99225 HCPCS outpatient 141 105.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 141 999999999 40.81 141 fee schedule "SUBSEQUENT OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PATIENT IS RESPONDING INADEQUATELY TO THERAPY OR HAS DEVELOPED A MINOR COMPLICATION. TYPICALLY, 25 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922501_1 CDM 987 RC 99225 HCPCS outpatient 141 105.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 141 999999999 40.81 141 fee schedule "SUBSEQUENT OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PATIENT IS RESPONDING INADEQUATELY TO THERAPY OR HAS DEVELOPED A MINOR COMPLICATION. TYPICALLY, 25 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922501_1 CDM 987 RC 99225 HCPCS outpatient 141 105.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 999999999 40.81 141 "SUBSEQUENT OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PATIENT IS RESPONDING INADEQUATELY TO THERAPY OR HAS DEVELOPED A MINOR COMPLICATION. TYPICALLY, 25 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922501_1 CDM 987 RC 99225 HCPCS outpatient 141 105.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 103.5 999999999 40.81 141 fee schedule "SUBSEQUENT OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PATIENT IS RESPONDING INADEQUATELY TO THERAPY OR HAS DEVELOPED A MINOR COMPLICATION. TYPICALLY, 25 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922501_1 CDM 987 RC 99225 HCPCS outpatient 141 105.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 103.5 999999999 40.81 141 fee schedule "SUBSEQUENT OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PATIENT IS RESPONDING INADEQUATELY TO THERAPY OR HAS DEVELOPED A MINOR COMPLICATION. TYPICALLY, 25 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922501_1 CDM 987 RC 99225 HCPCS outpatient 141 105.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 141 999999999 40.81 141 fee schedule "SUBSEQUENT OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PATIENT IS RESPONDING INADEQUATELY TO THERAPY OR HAS DEVELOPED A MINOR COMPLICATION. TYPICALLY, 25 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922501_1 CDM 987 RC 99225 HCPCS outpatient 141 105.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 999999999 40.81 141 "SUBSEQUENT OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PATIENT IS RESPONDING INADEQUATELY TO THERAPY OR HAS DEVELOPED A MINOR COMPLICATION. TYPICALLY, 25 MINUTES ARE SPENT AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT." 9879922501_1 CDM 987 RC 99225 HCPCS outpatient 141 105.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 141 999999999 40.81 141 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD OR LOW LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 45 MINUTES MUST BE MET OR EXCEEDED." 9879923401_1 CDM 987 RC 99234 HCPCS outpatient 345 258.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 142.69 999999999 55.02 345 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD OR LOW LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 45 MINUTES MUST BE MET OR EXCEEDED." 9879923401_1 CDM 987 RC 99234 HCPCS outpatient 345 258.75 AETNA MCR ADV AETNA MCR ADV 345 999999999 55.02 345 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD OR LOW LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 45 MINUTES MUST BE MET OR EXCEEDED." 9879923401_1 CDM 987 RC 99234 HCPCS outpatient 345 258.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 57.77 999999999 55.02 345 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD OR LOW LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 45 MINUTES MUST BE MET OR EXCEEDED." 9879923401_1 CDM 987 RC 99234 HCPCS outpatient 345 258.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 55.02 999999999 55.02 345 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD OR LOW LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 45 MINUTES MUST BE MET OR EXCEEDED." 9879923401_1 CDM 987 RC 99234 HCPCS outpatient 345 258.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 345 999999999 55.02 345 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD OR LOW LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 45 MINUTES MUST BE MET OR EXCEEDED." 9879923401_1 CDM 987 RC 99234 HCPCS outpatient 345 258.75 MOLINA MCAID MOLINA MCAID 57.77 999999999 55.02 345 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD OR LOW LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 45 MINUTES MUST BE MET OR EXCEEDED." 9879923401_1 CDM 987 RC 99234 HCPCS outpatient 345 258.75 MOLINA MCR ADV MOLINA MCR ADV 345 999999999 55.02 345 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD OR LOW LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 45 MINUTES MUST BE MET OR EXCEEDED." 9879923401_1 CDM 987 RC 99234 HCPCS outpatient 345 258.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 345 999999999 55.02 345 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD OR LOW LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 45 MINUTES MUST BE MET OR EXCEEDED." 9879923401_1 CDM 987 RC 99234 HCPCS outpatient 345 258.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 345 999999999 55.02 345 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD OR LOW LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 45 MINUTES MUST BE MET OR EXCEEDED." 9879923401_1 CDM 987 RC 99234 HCPCS outpatient 345 258.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 180.96 999999999 55.02 345 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD OR LOW LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 45 MINUTES MUST BE MET OR EXCEEDED." 9879923401_1 CDM 987 RC 99234 HCPCS outpatient 345 258.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 188.5 999999999 55.02 345 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD OR LOW LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 45 MINUTES MUST BE MET OR EXCEEDED." 9879923401_1 CDM 987 RC 99234 HCPCS outpatient 345 258.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 188.5 999999999 55.02 345 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD OR LOW LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 45 MINUTES MUST BE MET OR EXCEEDED." 9879923401_1 CDM 987 RC 99234 HCPCS outpatient 345 258.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 345 999999999 55.02 345 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD OR LOW LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 45 MINUTES MUST BE MET OR EXCEEDED." 9879923401_1 CDM 987 RC 99234 HCPCS outpatient 345 258.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 125.72 999999999 55.02 345 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD OR LOW LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 45 MINUTES MUST BE MET OR EXCEEDED." 9879923401_1 CDM 987 RC 99234 HCPCS outpatient 345 258.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 345 999999999 55.02 345 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 70 MINUTES MUST BE MET OR EXCEEDED." 9879923501_1 CDM 987 RC 99235 HCPCS outpatient 480 360 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 181.91 999999999 89.89 480 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 70 MINUTES MUST BE MET OR EXCEEDED." 9879923501_1 CDM 987 RC 99235 HCPCS outpatient 480 360 AETNA MCR ADV AETNA MCR ADV 480 999999999 89.89 480 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 70 MINUTES MUST BE MET OR EXCEEDED." 9879923501_1 CDM 987 RC 99235 HCPCS outpatient 480 360 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 94.38 999999999 89.89 480 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 70 MINUTES MUST BE MET OR EXCEEDED." 9879923501_1 CDM 987 RC 99235 HCPCS outpatient 480 360 COORDINATED CARE MCAID COORDINATED CARE MCAID 89.89 999999999 89.89 480 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 70 MINUTES MUST BE MET OR EXCEEDED." 9879923501_1 CDM 987 RC 99235 HCPCS outpatient 480 360 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 480 999999999 89.89 480 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 70 MINUTES MUST BE MET OR EXCEEDED." 9879923501_1 CDM 987 RC 99235 HCPCS outpatient 480 360 MOLINA MCAID MOLINA MCAID 94.38 999999999 89.89 480 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 70 MINUTES MUST BE MET OR EXCEEDED." 9879923501_1 CDM 987 RC 99235 HCPCS outpatient 480 360 MOLINA MCR ADV MOLINA MCR ADV 480 999999999 89.89 480 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 70 MINUTES MUST BE MET OR EXCEEDED." 9879923501_1 CDM 987 RC 99235 HCPCS outpatient 480 360 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 480 999999999 89.89 480 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 70 MINUTES MUST BE MET OR EXCEEDED." 9879923501_1 CDM 987 RC 99235 HCPCS outpatient 480 360 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 480 999999999 89.89 480 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 70 MINUTES MUST BE MET OR EXCEEDED." 9879923501_1 CDM 987 RC 99235 HCPCS outpatient 480 360 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 228.48 999999999 89.89 480 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 70 MINUTES MUST BE MET OR EXCEEDED." 9879923501_1 CDM 987 RC 99235 HCPCS outpatient 480 360 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 239.5 999999999 89.89 480 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 70 MINUTES MUST BE MET OR EXCEEDED." 9879923501_1 CDM 987 RC 99235 HCPCS outpatient 480 360 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 239.5 999999999 89.89 480 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 70 MINUTES MUST BE MET OR EXCEEDED." 9879923501_1 CDM 987 RC 99235 HCPCS outpatient 480 360 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 480 999999999 89.89 480 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 70 MINUTES MUST BE MET OR EXCEEDED." 9879923501_1 CDM 987 RC 99235 HCPCS outpatient 480 360 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 205.05 999999999 89.89 480 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 70 MINUTES MUST BE MET OR EXCEEDED." 9879923501_1 CDM 987 RC 99235 HCPCS outpatient 480 360 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 480 999999999 89.89 480 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND HIGH LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 85 MINUTES MUST BE MET OR EXCEEDED." 9879923601_1 CDM 987 RC 99236 HCPCS outpatient 550 412.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 233.27 999999999 117.31 550 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND HIGH LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 85 MINUTES MUST BE MET OR EXCEEDED." 9879923601_1 CDM 987 RC 99236 HCPCS outpatient 550 412.5 AETNA MCR ADV AETNA MCR ADV 550 999999999 117.31 550 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND HIGH LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 85 MINUTES MUST BE MET OR EXCEEDED." 9879923601_1 CDM 987 RC 99236 HCPCS outpatient 550 412.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 123.18 999999999 117.31 550 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND HIGH LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 85 MINUTES MUST BE MET OR EXCEEDED." 9879923601_1 CDM 987 RC 99236 HCPCS outpatient 550 412.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 117.31 999999999 117.31 550 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND HIGH LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 85 MINUTES MUST BE MET OR EXCEEDED." 9879923601_1 CDM 987 RC 99236 HCPCS outpatient 550 412.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 550 999999999 117.31 550 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND HIGH LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 85 MINUTES MUST BE MET OR EXCEEDED." 9879923601_1 CDM 987 RC 99236 HCPCS outpatient 550 412.5 MOLINA MCAID MOLINA MCAID 123.18 999999999 117.31 550 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND HIGH LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 85 MINUTES MUST BE MET OR EXCEEDED." 9879923601_1 CDM 987 RC 99236 HCPCS outpatient 550 412.5 MOLINA MCR ADV MOLINA MCR ADV 550 999999999 117.31 550 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND HIGH LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 85 MINUTES MUST BE MET OR EXCEEDED." 9879923601_1 CDM 987 RC 99236 HCPCS outpatient 550 412.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 550 999999999 117.31 550 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND HIGH LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 85 MINUTES MUST BE MET OR EXCEEDED." 9879923601_1 CDM 987 RC 99236 HCPCS outpatient 550 412.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 550 999999999 117.31 550 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND HIGH LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 85 MINUTES MUST BE MET OR EXCEEDED." 9879923601_1 CDM 987 RC 99236 HCPCS outpatient 550 412.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 294.24 999999999 117.31 550 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND HIGH LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 85 MINUTES MUST BE MET OR EXCEEDED." 9879923601_1 CDM 987 RC 99236 HCPCS outpatient 550 412.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 309 999999999 117.31 550 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND HIGH LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 85 MINUTES MUST BE MET OR EXCEEDED." 9879923601_1 CDM 987 RC 99236 HCPCS outpatient 550 412.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 309 999999999 117.31 550 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND HIGH LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 85 MINUTES MUST BE MET OR EXCEEDED." 9879923601_1 CDM 987 RC 99236 HCPCS outpatient 550 412.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 550 999999999 117.31 550 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND HIGH LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 85 MINUTES MUST BE MET OR EXCEEDED." 9879923601_1 CDM 987 RC 99236 HCPCS outpatient 550 412.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 267.9 999999999 117.31 550 fee schedule "HOSPITAL INPATIENT OR OBSERVATION CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND HIGH LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 85 MINUTES MUST BE MET OR EXCEEDED." 9879923601_1 CDM 987 RC 99236 HCPCS outpatient 550 412.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 550 999999999 117.31 550 fee schedule "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 5-10 MINUTES OF MEDICAL DISCUSSION" 98966_3 CDM 940 RC 98966 HCPCS outpatient 26 19.5 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 23.4 90 999999999 20.28 24.7 percent of total billed charges "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 5-10 MINUTES OF MEDICAL DISCUSSION" 98966_3 CDM 940 RC 98966 HCPCS outpatient 26 19.5 AETNA MCR ADV AETNA MCR ADV 20.28 78 999999999 20.28 24.7 percent of total billed charges "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 5-10 MINUTES OF MEDICAL DISCUSSION" 98966_3 CDM 940 RC 98966 HCPCS outpatient 26 19.5 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 22.77 87.57 999999999 20.28 24.7 percent of total billed charges "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 5-10 MINUTES OF MEDICAL DISCUSSION" 98966_3 CDM 940 RC 98966 HCPCS outpatient 26 19.5 COORDINATED CARE MCAID COORDINATED CARE MCAID 22.12 85.07 999999999 20.28 24.7 percent of total billed charges "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 5-10 MINUTES OF MEDICAL DISCUSSION" 98966_3 CDM 940 RC 98966 HCPCS outpatient 26 19.5 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 22.12 85.07 999999999 20.28 24.7 percent of total billed charges "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 5-10 MINUTES OF MEDICAL DISCUSSION" 98966_3 CDM 940 RC 98966 HCPCS outpatient 26 19.5 MOLINA MCAID MOLINA MCAID 21.68 83.4 999999999 20.28 24.7 percent of total billed charges "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 5-10 MINUTES OF MEDICAL DISCUSSION" 98966_3 CDM 940 RC 98966 HCPCS outpatient 26 19.5 MOLINA MCR ADV MOLINA MCR ADV 23.14 89 999999999 20.28 24.7 percent of total billed charges "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 5-10 MINUTES OF MEDICAL DISCUSSION" 98966_3 CDM 940 RC 98966 HCPCS outpatient 26 19.5 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 23.14 89 999999999 20.28 24.7 percent of total billed charges "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 5-10 MINUTES OF MEDICAL DISCUSSION" 98966_3 CDM 940 RC 98966 HCPCS outpatient 26 19.5 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 23.14 89 999999999 20.28 24.7 percent of total billed charges "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 5-10 MINUTES OF MEDICAL DISCUSSION" 98966_3 CDM 940 RC 98966 HCPCS outpatient 26 19.5 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 23.4 90 999999999 20.28 24.7 percent of total billed charges "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 5-10 MINUTES OF MEDICAL DISCUSSION" 98966_3 CDM 940 RC 98966 HCPCS outpatient 26 19.5 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 24.7 95 999999999 20.28 24.7 percent of total billed charges "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 5-10 MINUTES OF MEDICAL DISCUSSION" 98966_3 CDM 940 RC 98966 HCPCS outpatient 26 19.5 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 24.7 95 999999999 20.28 24.7 percent of total billed charges "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 5-10 MINUTES OF MEDICAL DISCUSSION" 98966_3 CDM 940 RC 98966 HCPCS outpatient 26 19.5 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 23.14 89 999999999 20.28 24.7 percent of total billed charges "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 5-10 MINUTES OF MEDICAL DISCUSSION" 98966_3 CDM 940 RC 98966 HCPCS outpatient 26 19.5 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 22.88 88 999999999 20.28 24.7 percent of total billed charges "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 5-10 MINUTES OF MEDICAL DISCUSSION" 98966_3 CDM 940 RC 98966 HCPCS outpatient 26 19.5 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 23.14 89 999999999 20.28 24.7 percent of total billed charges "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 11-20 MINUTES OF MEDICAL DISCUSSION" 98967_3 CDM 940 RC 98967 HCPCS outpatient 48 36 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 43.2 90 999999999 37.44 45.6 percent of total billed charges "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 11-20 MINUTES OF MEDICAL DISCUSSION" 98967_3 CDM 940 RC 98967 HCPCS outpatient 48 36 AETNA MCR ADV AETNA MCR ADV 37.44 78 999999999 37.44 45.6 percent of total billed charges "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 11-20 MINUTES OF MEDICAL DISCUSSION" 98967_3 CDM 940 RC 98967 HCPCS outpatient 48 36 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 42.03 87.57 999999999 37.44 45.6 percent of total billed charges "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 11-20 MINUTES OF MEDICAL DISCUSSION" 98967_3 CDM 940 RC 98967 HCPCS outpatient 48 36 COORDINATED CARE MCAID COORDINATED CARE MCAID 40.83 85.07 999999999 37.44 45.6 percent of total billed charges "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 11-20 MINUTES OF MEDICAL DISCUSSION" 98967_3 CDM 940 RC 98967 HCPCS outpatient 48 36 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 40.83 85.07 999999999 37.44 45.6 percent of total billed charges "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 11-20 MINUTES OF MEDICAL DISCUSSION" 98967_3 CDM 940 RC 98967 HCPCS outpatient 48 36 MOLINA MCAID MOLINA MCAID 40.03 83.4 999999999 37.44 45.6 percent of total billed charges "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 11-20 MINUTES OF MEDICAL DISCUSSION" 98967_3 CDM 940 RC 98967 HCPCS outpatient 48 36 MOLINA MCR ADV MOLINA MCR ADV 42.72 89 999999999 37.44 45.6 percent of total billed charges "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 11-20 MINUTES OF MEDICAL DISCUSSION" 98967_3 CDM 940 RC 98967 HCPCS outpatient 48 36 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 42.72 89 999999999 37.44 45.6 percent of total billed charges "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 11-20 MINUTES OF MEDICAL DISCUSSION" 98967_3 CDM 940 RC 98967 HCPCS outpatient 48 36 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 42.72 89 999999999 37.44 45.6 percent of total billed charges "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 11-20 MINUTES OF MEDICAL DISCUSSION" 98967_3 CDM 940 RC 98967 HCPCS outpatient 48 36 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 43.2 90 999999999 37.44 45.6 percent of total billed charges "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 11-20 MINUTES OF MEDICAL DISCUSSION" 98967_3 CDM 940 RC 98967 HCPCS outpatient 48 36 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 45.6 95 999999999 37.44 45.6 percent of total billed charges "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 11-20 MINUTES OF MEDICAL DISCUSSION" 98967_3 CDM 940 RC 98967 HCPCS outpatient 48 36 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 45.6 95 999999999 37.44 45.6 percent of total billed charges "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 11-20 MINUTES OF MEDICAL DISCUSSION" 98967_3 CDM 940 RC 98967 HCPCS outpatient 48 36 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 42.72 89 999999999 37.44 45.6 percent of total billed charges "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 11-20 MINUTES OF MEDICAL DISCUSSION" 98967_3 CDM 940 RC 98967 HCPCS outpatient 48 36 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 42.24 88 999999999 37.44 45.6 percent of total billed charges "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 11-20 MINUTES OF MEDICAL DISCUSSION" 98967_3 CDM 940 RC 98967 HCPCS outpatient 48 36 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 42.72 89 999999999 37.44 45.6 percent of total billed charges "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 21-30 MINUTES OF MEDICAL DISCUSSION" 98968_3 CDM 940 RC 98968 HCPCS outpatient 68 51 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 61.2 90 999999999 53.04 64.6 percent of total billed charges "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 21-30 MINUTES OF MEDICAL DISCUSSION" 98968_3 CDM 940 RC 98968 HCPCS outpatient 68 51 AETNA MCR ADV AETNA MCR ADV 53.04 78 999999999 53.04 64.6 percent of total billed charges "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 21-30 MINUTES OF MEDICAL DISCUSSION" 98968_3 CDM 940 RC 98968 HCPCS outpatient 68 51 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 59.55 87.57 999999999 53.04 64.6 percent of total billed charges "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 21-30 MINUTES OF MEDICAL DISCUSSION" 98968_3 CDM 940 RC 98968 HCPCS outpatient 68 51 COORDINATED CARE MCAID COORDINATED CARE MCAID 57.85 85.07 999999999 53.04 64.6 percent of total billed charges "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 21-30 MINUTES OF MEDICAL DISCUSSION" 98968_3 CDM 940 RC 98968 HCPCS outpatient 68 51 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 57.85 85.07 999999999 53.04 64.6 percent of total billed charges "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 21-30 MINUTES OF MEDICAL DISCUSSION" 98968_3 CDM 940 RC 98968 HCPCS outpatient 68 51 MOLINA MCAID MOLINA MCAID 56.71 83.4 999999999 53.04 64.6 percent of total billed charges "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 21-30 MINUTES OF MEDICAL DISCUSSION" 98968_3 CDM 940 RC 98968 HCPCS outpatient 68 51 MOLINA MCR ADV MOLINA MCR ADV 60.52 89 999999999 53.04 64.6 percent of total billed charges "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 21-30 MINUTES OF MEDICAL DISCUSSION" 98968_3 CDM 940 RC 98968 HCPCS outpatient 68 51 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 60.52 89 999999999 53.04 64.6 percent of total billed charges "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 21-30 MINUTES OF MEDICAL DISCUSSION" 98968_3 CDM 940 RC 98968 HCPCS outpatient 68 51 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 60.52 89 999999999 53.04 64.6 percent of total billed charges "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 21-30 MINUTES OF MEDICAL DISCUSSION" 98968_3 CDM 940 RC 98968 HCPCS outpatient 68 51 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 61.2 90 999999999 53.04 64.6 percent of total billed charges "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 21-30 MINUTES OF MEDICAL DISCUSSION" 98968_3 CDM 940 RC 98968 HCPCS outpatient 68 51 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 64.6 95 999999999 53.04 64.6 percent of total billed charges "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 21-30 MINUTES OF MEDICAL DISCUSSION" 98968_3 CDM 940 RC 98968 HCPCS outpatient 68 51 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 64.6 95 999999999 53.04 64.6 percent of total billed charges "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 21-30 MINUTES OF MEDICAL DISCUSSION" 98968_3 CDM 940 RC 98968 HCPCS outpatient 68 51 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 60.52 89 999999999 53.04 64.6 percent of total billed charges "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 21-30 MINUTES OF MEDICAL DISCUSSION" 98968_3 CDM 940 RC 98968 HCPCS outpatient 68 51 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 59.84 88 999999999 53.04 64.6 percent of total billed charges "TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 21-30 MINUTES OF MEDICAL DISCUSSION" 98968_3 CDM 940 RC 98968 HCPCS outpatient 68 51 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 60.52 89 999999999 53.04 64.6 percent of total billed charges "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 5-10 MINUTES" 98970_3 CDM 960 RC 98970 HCPCS outpatient 24 18 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 14.79 999999999 14.79 25.2 fee schedule "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 5-10 MINUTES" 98970_3 CDM 960 RC 98970 HCPCS outpatient 24 18 AETNA MCR ADV AETNA MCR ADV 24 999999999 14.79 25.2 fee schedule "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 5-10 MINUTES" 98970_3 CDM 960 RC 98970 HCPCS outpatient 24 18 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 25.2 999999999 14.79 25.2 fee schedule "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 5-10 MINUTES" 98970_3 CDM 960 RC 98970 HCPCS outpatient 24 18 COORDINATED CARE MCAID COORDINATED CARE MCAID 24 999999999 14.79 25.2 fee schedule "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 5-10 MINUTES" 98970_3 CDM 960 RC 98970 HCPCS outpatient 24 18 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 24 999999999 14.79 25.2 fee schedule "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 5-10 MINUTES" 98970_3 CDM 960 RC 98970 HCPCS outpatient 24 18 MOLINA MCAID MOLINA MCAID 25.2 999999999 14.79 25.2 fee schedule "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 5-10 MINUTES" 98970_3 CDM 960 RC 98970 HCPCS outpatient 24 18 MOLINA MCR ADV MOLINA MCR ADV 24 999999999 14.79 25.2 fee schedule "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 5-10 MINUTES" 98970_3 CDM 960 RC 98970 HCPCS outpatient 24 18 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 24 999999999 14.79 25.2 fee schedule "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 5-10 MINUTES" 98970_3 CDM 960 RC 98970 HCPCS outpatient 24 18 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 24 999999999 14.79 25.2 fee schedule "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 5-10 MINUTES" 98970_3 CDM 960 RC 98970 HCPCS outpatient 24 18 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 16.32 999999999 14.79 25.2 fee schedule "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 5-10 MINUTES" 98970_3 CDM 960 RC 98970 HCPCS outpatient 24 18 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 999999999 14.79 25.2 fee schedule "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 5-10 MINUTES" 98970_3 CDM 960 RC 98970 HCPCS outpatient 24 18 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 999999999 14.79 25.2 fee schedule "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 5-10 MINUTES" 98970_3 CDM 960 RC 98970 HCPCS outpatient 24 18 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 24 999999999 14.79 25.2 fee schedule "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 5-10 MINUTES" 98970_3 CDM 960 RC 98970 HCPCS outpatient 24 18 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 16 999999999 14.79 25.2 fee schedule "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 5-10 MINUTES" 98970_3 CDM 960 RC 98970 HCPCS outpatient 24 18 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 24 999999999 14.79 25.2 fee schedule "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 11-20 MINUTES" 98971_3 CDM 960 RC 98971 HCPCS outpatient 41 30.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 26.07 999999999 26.07 43.05 fee schedule "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 11-20 MINUTES" 98971_3 CDM 960 RC 98971 HCPCS outpatient 41 30.75 AETNA MCR ADV AETNA MCR ADV 41 999999999 26.07 43.05 fee schedule "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 11-20 MINUTES" 98971_3 CDM 960 RC 98971 HCPCS outpatient 41 30.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 43.05 999999999 26.07 43.05 fee schedule "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 11-20 MINUTES" 98971_3 CDM 960 RC 98971 HCPCS outpatient 41 30.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 41 999999999 26.07 43.05 fee schedule "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 11-20 MINUTES" 98971_3 CDM 960 RC 98971 HCPCS outpatient 41 30.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 41 999999999 26.07 43.05 fee schedule "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 11-20 MINUTES" 98971_3 CDM 960 RC 98971 HCPCS outpatient 41 30.75 MOLINA MCAID MOLINA MCAID 43.05 999999999 26.07 43.05 fee schedule "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 11-20 MINUTES" 98971_3 CDM 960 RC 98971 HCPCS outpatient 41 30.75 MOLINA MCR ADV MOLINA MCR ADV 41 999999999 26.07 43.05 fee schedule "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 11-20 MINUTES" 98971_3 CDM 960 RC 98971 HCPCS outpatient 41 30.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 41 999999999 26.07 43.05 fee schedule "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 11-20 MINUTES" 98971_3 CDM 960 RC 98971 HCPCS outpatient 41 30.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 41 999999999 26.07 43.05 fee schedule "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 11-20 MINUTES" 98971_3 CDM 960 RC 98971 HCPCS outpatient 41 30.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 28.8 999999999 26.07 43.05 fee schedule "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 11-20 MINUTES" 98971_3 CDM 960 RC 98971 HCPCS outpatient 41 30.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 999999999 26.07 43.05 fee schedule "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 11-20 MINUTES" 98971_3 CDM 960 RC 98971 HCPCS outpatient 41 30.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 999999999 26.07 43.05 fee schedule "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 11-20 MINUTES" 98971_3 CDM 960 RC 98971 HCPCS outpatient 41 30.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 41 999999999 26.07 43.05 fee schedule "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 11-20 MINUTES" 98971_3 CDM 960 RC 98971 HCPCS outpatient 41 30.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 28.33 999999999 26.07 43.05 fee schedule "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 11-20 MINUTES" 98971_3 CDM 960 RC 98971 HCPCS outpatient 41 30.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 41 999999999 26.07 43.05 fee schedule "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 21 OR MORE MINUTES" 98972_3 CDM 960 RC 98972 HCPCS outpatient 63 47.25 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 40.69 999999999 40.69 66.15 fee schedule "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 21 OR MORE MINUTES" 98972_3 CDM 960 RC 98972 HCPCS outpatient 63 47.25 AETNA MCR ADV AETNA MCR ADV 63 999999999 40.69 66.15 fee schedule "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 21 OR MORE MINUTES" 98972_3 CDM 960 RC 98972 HCPCS outpatient 63 47.25 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 66.15 999999999 40.69 66.15 fee schedule "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 21 OR MORE MINUTES" 98972_3 CDM 960 RC 98972 HCPCS outpatient 63 47.25 COORDINATED CARE MCAID COORDINATED CARE MCAID 63 999999999 40.69 66.15 fee schedule "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 21 OR MORE MINUTES" 98972_3 CDM 960 RC 98972 HCPCS outpatient 63 47.25 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 63 999999999 40.69 66.15 fee schedule "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 21 OR MORE MINUTES" 98972_3 CDM 960 RC 98972 HCPCS outpatient 63 47.25 MOLINA MCAID MOLINA MCAID 66.15 999999999 40.69 66.15 fee schedule "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 21 OR MORE MINUTES" 98972_3 CDM 960 RC 98972 HCPCS outpatient 63 47.25 MOLINA MCR ADV MOLINA MCR ADV 63 999999999 40.69 66.15 fee schedule "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 21 OR MORE MINUTES" 98972_3 CDM 960 RC 98972 HCPCS outpatient 63 47.25 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 63 999999999 40.69 66.15 fee schedule "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 21 OR MORE MINUTES" 98972_3 CDM 960 RC 98972 HCPCS outpatient 63 47.25 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 63 999999999 40.69 66.15 fee schedule "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 21 OR MORE MINUTES" 98972_3 CDM 960 RC 98972 HCPCS outpatient 63 47.25 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 45.13 999999999 40.69 66.15 fee schedule "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 21 OR MORE MINUTES" 98972_3 CDM 960 RC 98972 HCPCS outpatient 63 47.25 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 999999999 40.69 66.15 fee schedule "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 21 OR MORE MINUTES" 98972_3 CDM 960 RC 98972 HCPCS outpatient 63 47.25 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 999999999 40.69 66.15 fee schedule "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 21 OR MORE MINUTES" 98972_3 CDM 960 RC 98972 HCPCS outpatient 63 47.25 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 63 999999999 40.69 66.15 fee schedule "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 21 OR MORE MINUTES" 98972_3 CDM 960 RC 98972 HCPCS outpatient 63 47.25 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 41.59 999999999 40.69 66.15 fee schedule "NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL ONLINE DIGITAL ASSESSMENT AND MANAGEMENT, FOR AN ESTABLISHED PATIENT, FOR UP TO 7 DAYS, CUMULATIVE TIME DURING THE 7 DAYS; 21 OR MORE MINUTES" 98972_3 CDM 960 RC 98972 HCPCS outpatient 63 47.25 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 63 999999999 40.69 66.15 fee schedule MEDICAL TESTIMONY 99075_3 CDM 960 RC 99075 HCPCS outpatient 597 447.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 320 999999999 10 597 fee schedule MEDICAL TESTIMONY 99075_3 CDM 960 RC 99075 HCPCS outpatient 597 447.75 AETNA MCR ADV AETNA MCR ADV 597 999999999 10 597 fee schedule MEDICAL TESTIMONY 99075_3 CDM 960 RC 99075 HCPCS outpatient 597 447.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 10.5 999999999 10 597 fee schedule MEDICAL TESTIMONY 99075_3 CDM 960 RC 99075 HCPCS outpatient 597 447.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 10 999999999 10 597 fee schedule MEDICAL TESTIMONY 99075_3 CDM 960 RC 99075 HCPCS outpatient 597 447.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 597 999999999 10 597 fee schedule MEDICAL TESTIMONY 99075_3 CDM 960 RC 99075 HCPCS outpatient 597 447.75 MOLINA MCAID MOLINA MCAID 10.5 999999999 10 597 fee schedule MEDICAL TESTIMONY 99075_3 CDM 960 RC 99075 HCPCS outpatient 597 447.75 MOLINA MCR ADV MOLINA MCR ADV 597 999999999 10 597 fee schedule MEDICAL TESTIMONY 99075_3 CDM 960 RC 99075 HCPCS outpatient 597 447.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 597 999999999 10 597 fee schedule MEDICAL TESTIMONY 99075_3 CDM 960 RC 99075 HCPCS outpatient 597 447.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 597 999999999 10 597 fee schedule MEDICAL TESTIMONY 99075_3 CDM 960 RC 99075 HCPCS outpatient 597 447.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 999999999 10 597 MEDICAL TESTIMONY 99075_3 CDM 960 RC 99075 HCPCS outpatient 597 447.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 999999999 10 597 MEDICAL TESTIMONY 99075_3 CDM 960 RC 99075 HCPCS outpatient 597 447.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 999999999 10 597 MEDICAL TESTIMONY 99075_3 CDM 960 RC 99075 HCPCS outpatient 597 447.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 597 999999999 10 597 fee schedule MEDICAL TESTIMONY 99075_3 CDM 960 RC 99075 HCPCS outpatient 597 447.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 999999999 10 597 MEDICAL TESTIMONY 99075_3 CDM 960 RC 99075 HCPCS outpatient 597 447.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 597 999999999 10 597 fee schedule "SPECIAL REPORTS SUCH AS INSURANCE FORMS, MORE THAN THE INFORMATION CONVEYED IN THE USUAL MEDICAL COMMUNICATIONS OR STANDARD REPORTING FORM" 99080_3 CDM 510 RC 99080 HCPCS outpatient 96 72 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 86.4 90 999999999 74.88 91.2 percent of total billed charges "SPECIAL REPORTS SUCH AS INSURANCE FORMS, MORE THAN THE INFORMATION CONVEYED IN THE USUAL MEDICAL COMMUNICATIONS OR STANDARD REPORTING FORM" 99080_3 CDM 510 RC 99080 HCPCS outpatient 96 72 AETNA MCR ADV AETNA MCR ADV 74.88 78 999999999 74.88 91.2 percent of total billed charges "SPECIAL REPORTS SUCH AS INSURANCE FORMS, MORE THAN THE INFORMATION CONVEYED IN THE USUAL MEDICAL COMMUNICATIONS OR STANDARD REPORTING FORM" 99080_3 CDM 510 RC 99080 HCPCS outpatient 96 72 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 84.07 87.57 999999999 74.88 91.2 percent of total billed charges "SPECIAL REPORTS SUCH AS INSURANCE FORMS, MORE THAN THE INFORMATION CONVEYED IN THE USUAL MEDICAL COMMUNICATIONS OR STANDARD REPORTING FORM" 99080_3 CDM 510 RC 99080 HCPCS outpatient 96 72 COORDINATED CARE MCAID COORDINATED CARE MCAID 81.67 85.07 999999999 74.88 91.2 percent of total billed charges "SPECIAL REPORTS SUCH AS INSURANCE FORMS, MORE THAN THE INFORMATION CONVEYED IN THE USUAL MEDICAL COMMUNICATIONS OR STANDARD REPORTING FORM" 99080_3 CDM 510 RC 99080 HCPCS outpatient 96 72 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 81.67 85.07 999999999 74.88 91.2 percent of total billed charges "SPECIAL REPORTS SUCH AS INSURANCE FORMS, MORE THAN THE INFORMATION CONVEYED IN THE USUAL MEDICAL COMMUNICATIONS OR STANDARD REPORTING FORM" 99080_3 CDM 510 RC 99080 HCPCS outpatient 96 72 MOLINA MCAID MOLINA MCAID 80.06 83.4 999999999 74.88 91.2 percent of total billed charges "SPECIAL REPORTS SUCH AS INSURANCE FORMS, MORE THAN THE INFORMATION CONVEYED IN THE USUAL MEDICAL COMMUNICATIONS OR STANDARD REPORTING FORM" 99080_3 CDM 510 RC 99080 HCPCS outpatient 96 72 MOLINA MCR ADV MOLINA MCR ADV 85.44 89 999999999 74.88 91.2 percent of total billed charges "SPECIAL REPORTS SUCH AS INSURANCE FORMS, MORE THAN THE INFORMATION CONVEYED IN THE USUAL MEDICAL COMMUNICATIONS OR STANDARD REPORTING FORM" 99080_3 CDM 510 RC 99080 HCPCS outpatient 96 72 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 85.44 89 999999999 74.88 91.2 percent of total billed charges "SPECIAL REPORTS SUCH AS INSURANCE FORMS, MORE THAN THE INFORMATION CONVEYED IN THE USUAL MEDICAL COMMUNICATIONS OR STANDARD REPORTING FORM" 99080_3 CDM 510 RC 99080 HCPCS outpatient 96 72 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 85.44 89 999999999 74.88 91.2 percent of total billed charges "SPECIAL REPORTS SUCH AS INSURANCE FORMS, MORE THAN THE INFORMATION CONVEYED IN THE USUAL MEDICAL COMMUNICATIONS OR STANDARD REPORTING FORM" 99080_3 CDM 510 RC 99080 HCPCS outpatient 96 72 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 86.4 90 999999999 74.88 91.2 percent of total billed charges "SPECIAL REPORTS SUCH AS INSURANCE FORMS, MORE THAN THE INFORMATION CONVEYED IN THE USUAL MEDICAL COMMUNICATIONS OR STANDARD REPORTING FORM" 99080_3 CDM 510 RC 99080 HCPCS outpatient 96 72 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 999999999 74.88 91.2 other Non-Covered [Rev Code] ( 1*0 ) Term Line 43 "SPECIAL REPORTS SUCH AS INSURANCE FORMS, MORE THAN THE INFORMATION CONVEYED IN THE USUAL MEDICAL COMMUNICATIONS OR STANDARD REPORTING FORM" 99080_3 CDM 510 RC 99080 HCPCS outpatient 96 72 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 91.2 95 999999999 74.88 91.2 percent of total billed charges "SPECIAL REPORTS SUCH AS INSURANCE FORMS, MORE THAN THE INFORMATION CONVEYED IN THE USUAL MEDICAL COMMUNICATIONS OR STANDARD REPORTING FORM" 99080_3 CDM 510 RC 99080 HCPCS outpatient 96 72 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 85.44 89 999999999 74.88 91.2 percent of total billed charges "SPECIAL REPORTS SUCH AS INSURANCE FORMS, MORE THAN THE INFORMATION CONVEYED IN THE USUAL MEDICAL COMMUNICATIONS OR STANDARD REPORTING FORM" 99080_3 CDM 510 RC 99080 HCPCS outpatient 96 72 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 84.48 88 999999999 74.88 91.2 percent of total billed charges "SPECIAL REPORTS SUCH AS INSURANCE FORMS, MORE THAN THE INFORMATION CONVEYED IN THE USUAL MEDICAL COMMUNICATIONS OR STANDARD REPORTING FORM" 99080_3 CDM 510 RC 99080 HCPCS outpatient 96 72 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 85.44 89 999999999 74.88 91.2 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 9910081_1 CDM 762 RC G0378 HCPCS outpatient 668 501 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 601.2 90 999999999 521.04 634.6 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 9910081_1 CDM 762 RC G0378 HCPCS outpatient 668 501 AETNA MCR ADV AETNA MCR ADV 521.04 78 999999999 521.04 634.6 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 9910081_1 CDM 762 RC G0378 HCPCS outpatient 668 501 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 584.97 87.57 999999999 521.04 634.6 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 9910081_1 CDM 762 RC G0378 HCPCS outpatient 668 501 COORDINATED CARE MCAID COORDINATED CARE MCAID 568.27 85.07 999999999 521.04 634.6 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 9910081_1 CDM 762 RC G0378 HCPCS outpatient 668 501 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 568.27 85.07 999999999 521.04 634.6 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 9910081_1 CDM 762 RC G0378 HCPCS outpatient 668 501 MOLINA MCAID MOLINA MCAID 557.11 83.4 999999999 521.04 634.6 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 9910081_1 CDM 762 RC G0378 HCPCS outpatient 668 501 MOLINA MCR ADV MOLINA MCR ADV 594.52 89 999999999 521.04 634.6 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 9910081_1 CDM 762 RC G0378 HCPCS outpatient 668 501 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 594.52 89 999999999 521.04 634.6 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 9910081_1 CDM 762 RC G0378 HCPCS outpatient 668 501 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 594.52 89 999999999 521.04 634.6 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 9910081_1 CDM 762 RC G0378 HCPCS outpatient 668 501 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 601.2 90 999999999 521.04 634.6 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 9910081_1 CDM 762 RC G0378 HCPCS outpatient 668 501 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 634.6 95 999999999 521.04 634.6 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 9910081_1 CDM 762 RC G0378 HCPCS outpatient 668 501 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 634.6 95 999999999 521.04 634.6 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 9910081_1 CDM 762 RC G0378 HCPCS outpatient 668 501 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 594.52 89 999999999 521.04 634.6 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 9910081_1 CDM 762 RC G0378 HCPCS outpatient 668 501 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 587.84 88 999999999 521.04 634.6 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 9910081_1 CDM 762 RC G0378 HCPCS outpatient 668 501 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 594.52 89 999999999 521.04 634.6 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 9910082_1 CDM 762 RC G0378 HCPCS outpatient 52 39 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 46.8 90 999999999 40.56 49.4 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 9910082_1 CDM 762 RC G0378 HCPCS outpatient 52 39 AETNA MCR ADV AETNA MCR ADV 40.56 78 999999999 40.56 49.4 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 9910082_1 CDM 762 RC G0378 HCPCS outpatient 52 39 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 45.54 87.57 999999999 40.56 49.4 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 9910082_1 CDM 762 RC G0378 HCPCS outpatient 52 39 COORDINATED CARE MCAID COORDINATED CARE MCAID 44.24 85.07 999999999 40.56 49.4 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 9910082_1 CDM 762 RC G0378 HCPCS outpatient 52 39 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 44.24 85.07 999999999 40.56 49.4 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 9910082_1 CDM 762 RC G0378 HCPCS outpatient 52 39 MOLINA MCAID MOLINA MCAID 43.37 83.4 999999999 40.56 49.4 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 9910082_1 CDM 762 RC G0378 HCPCS outpatient 52 39 MOLINA MCR ADV MOLINA MCR ADV 46.28 89 999999999 40.56 49.4 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 9910082_1 CDM 762 RC G0378 HCPCS outpatient 52 39 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 46.28 89 999999999 40.56 49.4 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 9910082_1 CDM 762 RC G0378 HCPCS outpatient 52 39 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 46.28 89 999999999 40.56 49.4 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 9910082_1 CDM 762 RC G0378 HCPCS outpatient 52 39 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 46.8 90 999999999 40.56 49.4 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 9910082_1 CDM 762 RC G0378 HCPCS outpatient 52 39 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 49.4 95 999999999 40.56 49.4 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 9910082_1 CDM 762 RC G0378 HCPCS outpatient 52 39 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 49.4 95 999999999 40.56 49.4 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 9910082_1 CDM 762 RC G0378 HCPCS outpatient 52 39 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 46.28 89 999999999 40.56 49.4 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 9910082_1 CDM 762 RC G0378 HCPCS outpatient 52 39 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 45.76 88 999999999 40.56 49.4 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 9910082_1 CDM 762 RC G0378 HCPCS outpatient 52 39 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 46.28 89 999999999 40.56 49.4 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; INITIAL 15 MINUTES OF INTRASERVICE TIME, PATIENT AGE 5 YEARS OR OLDER" 99152_1 CDM 370 RC 99152 HCPCS outpatient 65 48.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 58.5 90 999999999 50.7 61.75 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; INITIAL 15 MINUTES OF INTRASERVICE TIME, PATIENT AGE 5 YEARS OR OLDER" 99152_1 CDM 370 RC 99152 HCPCS outpatient 65 48.75 AETNA MCR ADV AETNA MCR ADV 50.7 78 999999999 50.7 61.75 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; INITIAL 15 MINUTES OF INTRASERVICE TIME, PATIENT AGE 5 YEARS OR OLDER" 99152_1 CDM 370 RC 99152 HCPCS outpatient 65 48.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 56.92 87.57 999999999 50.7 61.75 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; INITIAL 15 MINUTES OF INTRASERVICE TIME, PATIENT AGE 5 YEARS OR OLDER" 99152_1 CDM 370 RC 99152 HCPCS outpatient 65 48.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 55.3 85.07 999999999 50.7 61.75 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; INITIAL 15 MINUTES OF INTRASERVICE TIME, PATIENT AGE 5 YEARS OR OLDER" 99152_1 CDM 370 RC 99152 HCPCS outpatient 65 48.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 55.3 85.07 999999999 50.7 61.75 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; INITIAL 15 MINUTES OF INTRASERVICE TIME, PATIENT AGE 5 YEARS OR OLDER" 99152_1 CDM 370 RC 99152 HCPCS outpatient 65 48.75 MOLINA MCAID MOLINA MCAID 54.21 83.4 999999999 50.7 61.75 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; INITIAL 15 MINUTES OF INTRASERVICE TIME, PATIENT AGE 5 YEARS OR OLDER" 99152_1 CDM 370 RC 99152 HCPCS outpatient 65 48.75 MOLINA MCR ADV MOLINA MCR ADV 57.85 89 999999999 50.7 61.75 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; INITIAL 15 MINUTES OF INTRASERVICE TIME, PATIENT AGE 5 YEARS OR OLDER" 99152_1 CDM 370 RC 99152 HCPCS outpatient 65 48.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 57.85 89 999999999 50.7 61.75 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; INITIAL 15 MINUTES OF INTRASERVICE TIME, PATIENT AGE 5 YEARS OR OLDER" 99152_1 CDM 370 RC 99152 HCPCS outpatient 65 48.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 57.85 89 999999999 50.7 61.75 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; INITIAL 15 MINUTES OF INTRASERVICE TIME, PATIENT AGE 5 YEARS OR OLDER" 99152_1 CDM 370 RC 99152 HCPCS outpatient 65 48.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 58.5 90 999999999 50.7 61.75 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; INITIAL 15 MINUTES OF INTRASERVICE TIME, PATIENT AGE 5 YEARS OR OLDER" 99152_1 CDM 370 RC 99152 HCPCS outpatient 65 48.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 61.75 95 999999999 50.7 61.75 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; INITIAL 15 MINUTES OF INTRASERVICE TIME, PATIENT AGE 5 YEARS OR OLDER" 99152_1 CDM 370 RC 99152 HCPCS outpatient 65 48.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 61.75 95 999999999 50.7 61.75 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; INITIAL 15 MINUTES OF INTRASERVICE TIME, PATIENT AGE 5 YEARS OR OLDER" 99152_1 CDM 370 RC 99152 HCPCS outpatient 65 48.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 57.85 89 999999999 50.7 61.75 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; INITIAL 15 MINUTES OF INTRASERVICE TIME, PATIENT AGE 5 YEARS OR OLDER" 99152_1 CDM 370 RC 99152 HCPCS outpatient 65 48.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 57.2 88 999999999 50.7 61.75 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; INITIAL 15 MINUTES OF INTRASERVICE TIME, PATIENT AGE 5 YEARS OR OLDER" 99152_1 CDM 370 RC 99152 HCPCS outpatient 65 48.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 57.85 89 999999999 50.7 61.75 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; INITIAL 15 MINUTES OF INTRASERVICE TIME, PATIENT AGE 5 YEARS OR OLDER" 99152_2 CDM 370 RC 99152 HCPCS outpatient 37.47 28.1 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 33.72 90 999999999 29.23 35.6 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; INITIAL 15 MINUTES OF INTRASERVICE TIME, PATIENT AGE 5 YEARS OR OLDER" 99152_2 CDM 370 RC 99152 HCPCS outpatient 37.47 28.1 AETNA MCR ADV AETNA MCR ADV 29.23 78 999999999 29.23 35.6 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; INITIAL 15 MINUTES OF INTRASERVICE TIME, PATIENT AGE 5 YEARS OR OLDER" 99152_2 CDM 370 RC 99152 HCPCS outpatient 37.47 28.1 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 32.81 87.57 999999999 29.23 35.6 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; INITIAL 15 MINUTES OF INTRASERVICE TIME, PATIENT AGE 5 YEARS OR OLDER" 99152_2 CDM 370 RC 99152 HCPCS outpatient 37.47 28.1 COORDINATED CARE MCAID COORDINATED CARE MCAID 31.88 85.07 999999999 29.23 35.6 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; INITIAL 15 MINUTES OF INTRASERVICE TIME, PATIENT AGE 5 YEARS OR OLDER" 99152_2 CDM 370 RC 99152 HCPCS outpatient 37.47 28.1 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 31.88 85.07 999999999 29.23 35.6 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; INITIAL 15 MINUTES OF INTRASERVICE TIME, PATIENT AGE 5 YEARS OR OLDER" 99152_2 CDM 370 RC 99152 HCPCS outpatient 37.47 28.1 MOLINA MCAID MOLINA MCAID 31.25 83.4 999999999 29.23 35.6 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; INITIAL 15 MINUTES OF INTRASERVICE TIME, PATIENT AGE 5 YEARS OR OLDER" 99152_2 CDM 370 RC 99152 HCPCS outpatient 37.47 28.1 MOLINA MCR ADV MOLINA MCR ADV 33.35 89 999999999 29.23 35.6 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; INITIAL 15 MINUTES OF INTRASERVICE TIME, PATIENT AGE 5 YEARS OR OLDER" 99152_2 CDM 370 RC 99152 HCPCS outpatient 37.47 28.1 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 33.35 89 999999999 29.23 35.6 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; INITIAL 15 MINUTES OF INTRASERVICE TIME, PATIENT AGE 5 YEARS OR OLDER" 99152_2 CDM 370 RC 99152 HCPCS outpatient 37.47 28.1 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 33.35 89 999999999 29.23 35.6 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; INITIAL 15 MINUTES OF INTRASERVICE TIME, PATIENT AGE 5 YEARS OR OLDER" 99152_2 CDM 370 RC 99152 HCPCS outpatient 37.47 28.1 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 33.72 90 999999999 29.23 35.6 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; INITIAL 15 MINUTES OF INTRASERVICE TIME, PATIENT AGE 5 YEARS OR OLDER" 99152_2 CDM 370 RC 99152 HCPCS outpatient 37.47 28.1 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 35.6 95 999999999 29.23 35.6 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; INITIAL 15 MINUTES OF INTRASERVICE TIME, PATIENT AGE 5 YEARS OR OLDER" 99152_2 CDM 370 RC 99152 HCPCS outpatient 37.47 28.1 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 35.6 95 999999999 29.23 35.6 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; INITIAL 15 MINUTES OF INTRASERVICE TIME, PATIENT AGE 5 YEARS OR OLDER" 99152_2 CDM 370 RC 99152 HCPCS outpatient 37.47 28.1 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 33.35 89 999999999 29.23 35.6 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; INITIAL 15 MINUTES OF INTRASERVICE TIME, PATIENT AGE 5 YEARS OR OLDER" 99152_2 CDM 370 RC 99152 HCPCS outpatient 37.47 28.1 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 32.97 88 999999999 29.23 35.6 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; INITIAL 15 MINUTES OF INTRASERVICE TIME, PATIENT AGE 5 YEARS OR OLDER" 99152_2 CDM 370 RC 99152 HCPCS outpatient 37.47 28.1 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 33.35 89 999999999 29.23 35.6 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; EACH ADDITIONAL 15 MINUTES INTRASERVICE TIME (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 99153_1 CDM 370 RC 99153 HCPCS outpatient 41 30.75 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 36.9 90 999999999 31.98 38.95 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; EACH ADDITIONAL 15 MINUTES INTRASERVICE TIME (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 99153_1 CDM 370 RC 99153 HCPCS outpatient 41 30.75 AETNA MCR ADV AETNA MCR ADV 31.98 78 999999999 31.98 38.95 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; EACH ADDITIONAL 15 MINUTES INTRASERVICE TIME (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 99153_1 CDM 370 RC 99153 HCPCS outpatient 41 30.75 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 35.9 87.57 999999999 31.98 38.95 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; EACH ADDITIONAL 15 MINUTES INTRASERVICE TIME (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 99153_1 CDM 370 RC 99153 HCPCS outpatient 41 30.75 COORDINATED CARE MCAID COORDINATED CARE MCAID 34.88 85.07 999999999 31.98 38.95 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; EACH ADDITIONAL 15 MINUTES INTRASERVICE TIME (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 99153_1 CDM 370 RC 99153 HCPCS outpatient 41 30.75 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 34.88 85.07 999999999 31.98 38.95 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; EACH ADDITIONAL 15 MINUTES INTRASERVICE TIME (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 99153_1 CDM 370 RC 99153 HCPCS outpatient 41 30.75 MOLINA MCAID MOLINA MCAID 34.19 83.4 999999999 31.98 38.95 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; EACH ADDITIONAL 15 MINUTES INTRASERVICE TIME (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 99153_1 CDM 370 RC 99153 HCPCS outpatient 41 30.75 MOLINA MCR ADV MOLINA MCR ADV 36.49 89 999999999 31.98 38.95 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; EACH ADDITIONAL 15 MINUTES INTRASERVICE TIME (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 99153_1 CDM 370 RC 99153 HCPCS outpatient 41 30.75 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 36.49 89 999999999 31.98 38.95 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; EACH ADDITIONAL 15 MINUTES INTRASERVICE TIME (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 99153_1 CDM 370 RC 99153 HCPCS outpatient 41 30.75 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 36.49 89 999999999 31.98 38.95 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; EACH ADDITIONAL 15 MINUTES INTRASERVICE TIME (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 99153_1 CDM 370 RC 99153 HCPCS outpatient 41 30.75 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 36.9 90 999999999 31.98 38.95 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; EACH ADDITIONAL 15 MINUTES INTRASERVICE TIME (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 99153_1 CDM 370 RC 99153 HCPCS outpatient 41 30.75 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 38.95 95 999999999 31.98 38.95 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; EACH ADDITIONAL 15 MINUTES INTRASERVICE TIME (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 99153_1 CDM 370 RC 99153 HCPCS outpatient 41 30.75 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 38.95 95 999999999 31.98 38.95 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; EACH ADDITIONAL 15 MINUTES INTRASERVICE TIME (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 99153_1 CDM 370 RC 99153 HCPCS outpatient 41 30.75 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 36.49 89 999999999 31.98 38.95 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; EACH ADDITIONAL 15 MINUTES INTRASERVICE TIME (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 99153_1 CDM 370 RC 99153 HCPCS outpatient 41 30.75 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 36.08 88 999999999 31.98 38.95 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; EACH ADDITIONAL 15 MINUTES INTRASERVICE TIME (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 99153_1 CDM 370 RC 99153 HCPCS outpatient 41 30.75 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 36.49 89 999999999 31.98 38.95 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; EACH ADDITIONAL 15 MINUTES INTRASERVICE TIME (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 99153_2 CDM 370 RC 99153 HCPCS outpatient 33.12 24.84 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 29.81 90 999999999 25.83 31.46 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; EACH ADDITIONAL 15 MINUTES INTRASERVICE TIME (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 99153_2 CDM 370 RC 99153 HCPCS outpatient 33.12 24.84 AETNA MCR ADV AETNA MCR ADV 25.83 78 999999999 25.83 31.46 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; EACH ADDITIONAL 15 MINUTES INTRASERVICE TIME (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 99153_2 CDM 370 RC 99153 HCPCS outpatient 33.12 24.84 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 29 87.57 999999999 25.83 31.46 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; EACH ADDITIONAL 15 MINUTES INTRASERVICE TIME (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 99153_2 CDM 370 RC 99153 HCPCS outpatient 33.12 24.84 COORDINATED CARE MCAID COORDINATED CARE MCAID 28.18 85.07 999999999 25.83 31.46 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; EACH ADDITIONAL 15 MINUTES INTRASERVICE TIME (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 99153_2 CDM 370 RC 99153 HCPCS outpatient 33.12 24.84 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 28.18 85.07 999999999 25.83 31.46 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; EACH ADDITIONAL 15 MINUTES INTRASERVICE TIME (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 99153_2 CDM 370 RC 99153 HCPCS outpatient 33.12 24.84 MOLINA MCAID MOLINA MCAID 27.62 83.4 999999999 25.83 31.46 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; EACH ADDITIONAL 15 MINUTES INTRASERVICE TIME (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 99153_2 CDM 370 RC 99153 HCPCS outpatient 33.12 24.84 MOLINA MCR ADV MOLINA MCR ADV 29.48 89 999999999 25.83 31.46 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; EACH ADDITIONAL 15 MINUTES INTRASERVICE TIME (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 99153_2 CDM 370 RC 99153 HCPCS outpatient 33.12 24.84 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 29.48 89 999999999 25.83 31.46 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; EACH ADDITIONAL 15 MINUTES INTRASERVICE TIME (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 99153_2 CDM 370 RC 99153 HCPCS outpatient 33.12 24.84 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 29.48 89 999999999 25.83 31.46 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; EACH ADDITIONAL 15 MINUTES INTRASERVICE TIME (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 99153_2 CDM 370 RC 99153 HCPCS outpatient 33.12 24.84 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 29.81 90 999999999 25.83 31.46 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; EACH ADDITIONAL 15 MINUTES INTRASERVICE TIME (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 99153_2 CDM 370 RC 99153 HCPCS outpatient 33.12 24.84 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 31.46 95 999999999 25.83 31.46 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; EACH ADDITIONAL 15 MINUTES INTRASERVICE TIME (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 99153_2 CDM 370 RC 99153 HCPCS outpatient 33.12 24.84 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 31.46 95 999999999 25.83 31.46 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; EACH ADDITIONAL 15 MINUTES INTRASERVICE TIME (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 99153_2 CDM 370 RC 99153 HCPCS outpatient 33.12 24.84 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 29.48 89 999999999 25.83 31.46 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; EACH ADDITIONAL 15 MINUTES INTRASERVICE TIME (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 99153_2 CDM 370 RC 99153 HCPCS outpatient 33.12 24.84 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 29.15 88 999999999 25.83 31.46 percent of total billed charges "MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; EACH ADDITIONAL 15 MINUTES INTRASERVICE TIME (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)" 99153_2 CDM 370 RC 99153 HCPCS outpatient 33.12 24.84 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 29.48 89 999999999 25.83 31.46 percent of total billed charges IPECAC OR SIMILAR ADMINISTRATION FOR INDIVIDUAL EMESIS AND CONTINUED OBSERVATION UNTIL STOMACH ADEQUATELY EMPTIED OF POISON 99175_3 CDM 960 RC 99175 HCPCS outpatient 60 45 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 41.75 999999999 18.09 60 fee schedule IPECAC OR SIMILAR ADMINISTRATION FOR INDIVIDUAL EMESIS AND CONTINUED OBSERVATION UNTIL STOMACH ADEQUATELY EMPTIED OF POISON 99175_3 CDM 960 RC 99175 HCPCS outpatient 60 45 AETNA MCR ADV AETNA MCR ADV 60 999999999 18.09 60 fee schedule IPECAC OR SIMILAR ADMINISTRATION FOR INDIVIDUAL EMESIS AND CONTINUED OBSERVATION UNTIL STOMACH ADEQUATELY EMPTIED OF POISON 99175_3 CDM 960 RC 99175 HCPCS outpatient 60 45 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 18.99 999999999 18.09 60 fee schedule IPECAC OR SIMILAR ADMINISTRATION FOR INDIVIDUAL EMESIS AND CONTINUED OBSERVATION UNTIL STOMACH ADEQUATELY EMPTIED OF POISON 99175_3 CDM 960 RC 99175 HCPCS outpatient 60 45 COORDINATED CARE MCAID COORDINATED CARE MCAID 18.09 999999999 18.09 60 fee schedule IPECAC OR SIMILAR ADMINISTRATION FOR INDIVIDUAL EMESIS AND CONTINUED OBSERVATION UNTIL STOMACH ADEQUATELY EMPTIED OF POISON 99175_3 CDM 960 RC 99175 HCPCS outpatient 60 45 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 60 999999999 18.09 60 fee schedule IPECAC OR SIMILAR ADMINISTRATION FOR INDIVIDUAL EMESIS AND CONTINUED OBSERVATION UNTIL STOMACH ADEQUATELY EMPTIED OF POISON 99175_3 CDM 960 RC 99175 HCPCS outpatient 60 45 MOLINA MCAID MOLINA MCAID 18.99 999999999 18.09 60 fee schedule IPECAC OR SIMILAR ADMINISTRATION FOR INDIVIDUAL EMESIS AND CONTINUED OBSERVATION UNTIL STOMACH ADEQUATELY EMPTIED OF POISON 99175_3 CDM 960 RC 99175 HCPCS outpatient 60 45 MOLINA MCR ADV MOLINA MCR ADV 60 999999999 18.09 60 fee schedule IPECAC OR SIMILAR ADMINISTRATION FOR INDIVIDUAL EMESIS AND CONTINUED OBSERVATION UNTIL STOMACH ADEQUATELY EMPTIED OF POISON 99175_3 CDM 960 RC 99175 HCPCS outpatient 60 45 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 60 999999999 18.09 60 fee schedule IPECAC OR SIMILAR ADMINISTRATION FOR INDIVIDUAL EMESIS AND CONTINUED OBSERVATION UNTIL STOMACH ADEQUATELY EMPTIED OF POISON 99175_3 CDM 960 RC 99175 HCPCS outpatient 60 45 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 60 999999999 18.09 60 fee schedule IPECAC OR SIMILAR ADMINISTRATION FOR INDIVIDUAL EMESIS AND CONTINUED OBSERVATION UNTIL STOMACH ADEQUATELY EMPTIED OF POISON 99175_3 CDM 960 RC 99175 HCPCS outpatient 60 45 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 23.05 999999999 18.09 60 fee schedule IPECAC OR SIMILAR ADMINISTRATION FOR INDIVIDUAL EMESIS AND CONTINUED OBSERVATION UNTIL STOMACH ADEQUATELY EMPTIED OF POISON 99175_3 CDM 960 RC 99175 HCPCS outpatient 60 45 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 36.5 999999999 18.09 60 fee schedule IPECAC OR SIMILAR ADMINISTRATION FOR INDIVIDUAL EMESIS AND CONTINUED OBSERVATION UNTIL STOMACH ADEQUATELY EMPTIED OF POISON 99175_3 CDM 960 RC 99175 HCPCS outpatient 60 45 ASURIS INDIV AND FAMILY ASURIS INDIV AND FAMILY 36.5 999999999 18.09 60 fee schedule IPECAC OR SIMILAR ADMINISTRATION FOR INDIVIDUAL EMESIS AND CONTINUED OBSERVATION UNTIL STOMACH ADEQUATELY EMPTIED OF POISON 99175_3 CDM 960 RC 99175 HCPCS outpatient 60 45 ASURIS NW HLTH MCR ADV ASURIS NW HLTH MCR ADV 60 999999999 18.09 60 fee schedule IPECAC OR SIMILAR ADMINISTRATION FOR INDIVIDUAL EMESIS AND CONTINUED OBSERVATION UNTIL STOMACH ADEQUATELY EMPTIED OF POISON 99175_3 CDM 960 RC 99175 HCPCS outpatient 60 45 PREMERA FIRST-ALL PLANS PREMERA FIRST-ALL PLANS 41.13 999999999 18.09 60 fee schedule IPECAC OR SIMILAR ADMINISTRATION FOR INDIVIDUAL EMESIS AND CONTINUED OBSERVATION UNTIL STOMACH ADEQUATELY EMPTIED OF POISON 99175_3 CDM 960 RC 99175 HCPCS outpatient 60 45 ASSURED HOSPICE MCR-ALL PLANS ASSURED HOSPICE MCR-ALL PLANS 60 999999999 18.09 60 fee schedule "OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 15 MINUTES MUST BE MET OR EXCEEDED." 99202_3 CDM 510 RC 99202 HCPCS outpatient 148 111 AETNA-ALL OTHER PLANS AETNA-ALL OTHER PLANS 133.2 90 999999999 115.44 140.6 percent of total billed charges "OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 15 MINUTES MUST BE MET OR EXCEEDED." 99202_3 CDM 510 RC 99202 HCPCS outpatient 148 111 AETNA MCR ADV AETNA MCR ADV 115.44 78 999999999 115.44 140.6 percent of total billed charges "OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 15 MINUTES MUST BE MET OR EXCEEDED." 99202_3 CDM 510 RC 99202 HCPCS outpatient 148 111 AMERIGROUP MCAID-ALL PLANS AMERIGROUP MCAID-ALL PLANS 129.6 87.57 999999999 115.44 140.6 percent of total billed charges "OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 15 MINUTES MUST BE MET OR EXCEEDED." 99202_3 CDM 510 RC 99202 HCPCS outpatient 148 111 COORDINATED CARE MCAID COORDINATED CARE MCAID 125.9 85.07 999999999 115.44 140.6 percent of total billed charges "OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 15 MINUTES MUST BE MET OR EXCEEDED." 99202_3 CDM 510 RC 99202 HCPCS outpatient 148 111 COORDINATED CARE AMBETTER-ALL OTHER PLANS COORDINATED CARE AMBETTER-ALL OTHER PLANS 125.9 85.07 999999999 115.44 140.6 percent of total billed charges "OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 15 MINUTES MUST BE MET OR EXCEEDED." 99202_3 CDM 510 RC 99202 HCPCS outpatient 148 111 MOLINA MCAID MOLINA MCAID 123.43 83.4 999999999 115.44 140.6 percent of total billed charges "OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 15 MINUTES MUST BE MET OR EXCEEDED." 99202_3 CDM 510 RC 99202 HCPCS outpatient 148 111 MOLINA MCR ADV MOLINA MCR ADV 131.72 89 999999999 115.44 140.6 percent of total billed charges "OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 15 MINUTES MUST BE MET OR EXCEEDED." 99202_3 CDM 510 RC 99202 HCPCS outpatient 148 111 MOLINA MARKEPLACE-ALL OTHER PLANS MOLINA MARKEPLACE-ALL OTHER PLANS 131.72 89 999999999 115.44 140.6 percent of total billed charges "OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 15 MINUTES MUST BE MET OR EXCEEDED." 99202_3 CDM 510 RC 99202 HCPCS outpatient 148 111 TRIWEST VA-ALL PLANS TRIWEST VA-ALL PLANS 131.72 89 999999999 115.44 140.6 percent of total billed charges "OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 15 MINUTES MUST BE MET OR EXCEEDED." 99202_3 CDM 510 RC 99202 HCPCS outpatient 148 111 UHC COMM-ALL PLANS UHC COMM-ALL PLANS 133.2 90 999999999 115.44 140.6 percent of total billed charges "OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 15 MINUTES MUST BE MET OR EXCEEDED." 99202_3 CDM 510 RC 99202 HCPCS outpatient 148 111 ASURIS NW HEALTH-ALL OTHER PLANS ASURIS NW HEALTH-ALL OTHER PLANS 999999999 115.44 140.6 othe